EmailMeForm
Questionnaire for You, the BC Survivor
Perhaps together WE can figure out what we've all got in common, in hopes to save future generations! Thank you in advance for your help.
Please Answer the Following Questions - Keep in mind these questions are PRE cancer.
Did you live by power lines?
Yes
No
Unsure
Did you live by a slop ditch?
Yes
No
Unsure
Did you wear perfume?
Yes
No
Unsure
Did you use tampons?
Yes
No
Unsure
Did you eat prepackaged meals often? Ex.: Hamburger Helper, Mac n Cheese..
Yes
No
Unsure
Did you wear lipstick?
Yes
No
Unsure
Did you wear body lotions containing parabens?
Yes
No
Unsure
Did you live in the country?
Yes
No
Unsure
Did you drink well water?
Yes
No
Unsure
Did you live in the city?
Yes
No
Unsure
Did you take birth control pills?
Yes
No
Unsure
Did you drink alcohol?
Yes
No
Unsure
Did you drink soda pop?
Yes
No
Unsure
Did you drink diet soda pop?
Yes
No
Unsure
Did you drink Kool-Aid?
Yes
No
Unsure
Did you eat a lot of candy?
Yes
No
Unsure
Did you eat dairy?
Yes
No
Unsure
Did you watch a lot of TV?
Yes
No
Unsure
Did you wear underwire bras?
Yes
No
Unsure
Did you smoke?
Yes
No
Unsure
Did you wear anti-perspirant?
Yes
No
Unsure
Did you get all of your immunizations as a child?
Yes
No
Unsure
Did you frequent the Dentist growing up?
Yes
No
Unsure
Did you have many dental XRays?
Yes
No
Unsure
Did you have dental root canals?
Yes
No
Unsure
Did you have silver dental fillings?
Yes
No
Unsure
Were you a night owl?
Yes
No
Unsure
Were you obese?
Yes
No
Unsure
Did you exercise?
Yes
No
Unsure
Did you sit a lot at work?
Yes
No
Unsure
Did you notice a lot of stress prior to diagnosis?
Yes
No
Unsure
Did you have diabetes?
Yes
No
Unsure
Did you have gestational diabetes?
Yes
No
Unsure
Did you have a mammogram prior to diagnosis?
Yes
No
Unsure
WiFi in the house?
Yes
No
Unsure
Mold/Mildew smell in home?
Yes
No
Unsure
Did you use a cell phone?
Yes
No
Unsure
Were you ever on birth control pills?
Yes
No
Unsure
*If you stated yes to mammogram prior to diagnosis, please tell us how long before.
Please select
1-6 months
6-12 months
1-5 years
What region did/do you live in?
Please select
North
South
East
West
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