N.C.R.F. Questionnaire

This questionnaire and all correspondence are strictly confidential. The individual responses are not shared with anyone other than the submitting person. Graphs or charts created as a result of the questionnaires will not reveal the participants identities, and will be demonstrated on this site intended to aid towards our research. No part nor information of this website is to be sold and all information will be held in strict confidence.

Would you please fill out our questionnaire and press the submit button. This will help give us a better understanding of your viewpoints which will help and support our efforts to understand cancer's chemistry requirements and how to not only control it, but also to better educate our society in effort to provide a more enjoyable life.
Name
Age
Address
City
State
Zip
Email
Phone Number 1-( ) - For US Phone Numbers
Fax Number 1-( ) - For US Fax Numbers
Phone Number International Phone Numbers
Fax Number International Fax Numbers
Best Time to Call
Type of Illness:
Diagnosis Date:
What were the early symptoms leading to exam:
Describe the basic situation:
Treatments Received:
1.Is there a history of cancer in your family?
If YES, does it tend to be the same type cancer?

2. In an effort to determine whether genetics or randomness is a strong factor, if there is a history of cancer in your family:
a. What types of cancer have your family members, past and present, experienced?
b. Is it predominant on mother's side or father's side? If both, what type of cancer is predominant on each side?
c. Did progression follow similar pathways if others had same cancer?
If there were similar pathways, what were the pathways?
d. Please indicate which cancer victims smoked or did not smoke
e. Please indicate which cancer victims drink or did not drink alcohol
f. Were their twins, triplets, etc., who had cancer, whether one or both of them?
3. Mental attitude is of interest.
Whether a person has a positive or negative attitude can possibly affect their overall health.
Did those with cancer have a positive or negative outlook prior to their cancer diagnosis?
4. Were there family members with an opposite outlook, and did they have cancer?
5. Pessimism and optimism bring interesting results. Which type character reflected those in questions #'s 3 & 4?
6. Indoor environments are of interest because of the known value of natural sunlight to the body. Was the cancer patient one who was out in the sun most of the time or one who tended to stay indoors?
7. What geographical area is the person located?
8. Nutrition is important for overall well-being. What diet did those in the family generally follow throughout their lives?
Diet of those with cancer
Diet of those without cancer
9.Upon cancer diagnosis, was the diet changed and how willing was the patient to change the diet?
10. What diet change(s) seemed most beneficial?
11. What foods seemed to aggravate the situation?
12. Was exercise a factor between those who did and did not have cancer?
13. After cancer diagnosis, was exercise considered to be important to the patient?
14. After diagnosis, was there an attitude change, and was it positive or negative?
15. After diagnosis, was there a change in outlook, and was it positive or negative?

16. Since cancer diagnosis, How did family members who did not have cancer change their way of life in any way?
17. What do you feel is relevant to prevent cancer? What have you found that you believe will help you prevent cancer?

18. What do you feel is a correct or incorrect strategy in current cancer research, how do you feel it can be improved?
If there is anything you would like to add to the questionnaire please feel free to add it here