Environmental Causes of Cancer
Survey Form

PLEASE HELP US IDENTIFY CAUSES OF CHILD CANCER
BY ANSWERING THE QUESTIONS BELOW

Research Projected being conducted by Chem-Tox
Richard Pressinger (M.Ed)
Wayne Sinclair (M.D.)

Thank you for taking the time to complete this important SURVEY regarding environmental factors which show evidence of  increasing child cancers in the U.S. and abroad..  As stated in the previously listed New York Times article, child cancer now  affects one in every 600 children and continues to grow approximately 1% per  year.  This steady yearly increase provides strong evidence for environmental/chemical factors that can increase attrition to the parent or child's genetic structure.    These chemical exposures can occur in the home, school, job, as well as from food sources and use of common home products.  Chemical exposures can also weaken or damage the genetic material to the father (or mother) from job occupation chemical exposures. 

Unfortunately, because of the large number of chemical exposure sources in today's society, defining the significance of any one chemical is often difficult.  Therefore, we have designed the following SURVEY to help identify which chemicals may be a higher risk for contributing to cancer as well as looking for increased risks occurring from interactions between chemicals that would otherwise be overlooked.

HOW IS OUR CHILD CANCER RESEARCH PROGRESSING?

After viewing over 300 surveys returned to date, the information suggests an increased risk for a child developing cancer when exposed to several (even moderate) chemical exposures simultaneously or in a close time period.  In other words, if the child is exposed to just one environmental factor, his/her genetic structure and natural defenses (i.e. liver detoxification and brain defenses), may be able to tolerate the insult, however, if exposure to several chemical factors occur either simultaneously or in a relatively close time period - the body's defenses and genes involved in cancer growth can be overwhelmed, especially in a young child whose defenses and genetics are far more susceptible to harm than an adults.  This would explain why a child exposed for even a one year period to a combination of lawn or home pesticides, home remodeling chemicals, repeated cosmetics, room painting etc.etc. would be at a higher risk for developing cancer.  When answering questions about job occupations, please be as detailed as possible as survey results appear to suggest the potential of male job occupations involved in chemical exposure (i.e. pesticides/engine exhaust/painting etc.) as a factor in weakening the 65+ day male sperm development process, thereby increasing susceptibility to the offspring.

If you have come to this web site directly, you may wish to see our web site which has summarized what is already known regarding child cancer and environmental causes.   The site address is www.chem-tox.com/cancerchildren - if you choose to view that web site first,  please come back to complete this survey. 

Thank you - Wayne Sinclair, M.D.,
Richard Pressinger (M.Ed.) - CHEM-TOX.COM

ATTENTION - This form has been temporarily taken off-line
 due to an increased use by spammers.  
We will be working on developing an alternative form.
Thank you - Chem-Tox
Type of cancer originally diagnosed

Age of patient when cancer was diagnosed
Age of patient currently
(if deceased, child's age at death and year)
Sex of patient male    female
Age of mother when child was born under 20     20-30      over 30
Age of father when child was born under 20     20-30       over 30
Job occupation of mother during pregnancy
Job occupation of father at time of
conception and for previous 65 days
(65 days is the time
required for sperm development)

The majority of questions below will ask about possible sources of chemical exposure,
and therefore, potential contributors to damaging a child's genetic structure, immune system or cell growth control mechanisms. 
Please answer the following questions to the best of your recollection
for the period 3 months prior to conception (the time period required for male sperm development)
and for the period from birth up until cancer diagnosis.
The 67 questions should take between 10-20 minutes to complete.  Thank you very much....

Survey Questions 

Answers should be for the time period only from 3 months before conception to the time of cancer diagnosis
Did child ever spend time at mother or father's place of employment....After school, holidays etc.
If yes, please explain
How close was home to
currently active agriculture/farming areas -
(such as citrus groves, corn, cotton, etc)?
Please be specific.

If answer is yes to above question,
What was the type of agriculture?
If no agriculture areas are currently close to the home, was there ever any agriculture conducted in the past around your home? - explain
Did the child ever visit friends or relatives who lived close to agriculture growing areas?
If yes, describe farming type, distance and how often child visited.
Did either parent follow the mosquito trucks back in the 60's & 70's which emitted a pesticide fog plume?   If yes, how often.
Distance to the closest golf course?
Type of HEATER used inside the home.  Electric?  Gas?  Oil Burning? 
Small Kerosene Heaters?  Explain.
Type of oven used in home - electric? - gas?
How often were roach and ant pesticides applied indoors? Were they applied by family members or professional pest control.
Were lawn pesticides ever applied? If yes, how often and by which company?
Were shrubbery pesticides ever applied?
If yes, how often and by which company?
Were termite treatments ever applied while living in the home? Explain.
Did the mother consume diet drinks containing aspartame (nutra-sweet) during pregnancy.
If yes, how often?
Did father consume diet drinks prior to conception? If yes, how often?
Were flea bombs (aerosol or smoke vapor) ever used in the home?
If yes, what type and how often?
Were liquid or powder flea treatments ever applied to the interior of the home – this is where the pesticide is usually sprayed over the entire carpet and/or couches - explain?
What type of laundry detergent was used?
Was any fabric softener used?  If yes – what type of product - 
Brand Name – liquid or sheets?
How often was bleach used as a cleaning or disinfecting agent in the home?
How often was pine cleaner used in the home?
Were any fragrance products (such as plug-ins – or aerosols) ever intentionally used to add fragrance to the household air? 
Year home was built that family was living in at the time of cancer diagnosis?
Was home wood or concrete block construction?
Type of flooring – carpet – tile etc? Explain if different for different rooms?
Was new carpet ever installed during the three months before conception up until cancer diagnosis - if yes, when and where was it installed? - please be specific
Were any rooms painted  from 6 months prior to conception up until cancer diagnosis? 
If yes, how long before cancer diagnosis
and which rooms were painted?
Was latex or oil paint used?
Also, if you recall the brand name, please list - Benjamin Moore, Walmart, Glidden etc.
What type of pet was in the home?
How often was the pet treated for fleas with chemical flea treatments?
How often did mother use perfume?
What type if known?
How often did father use colognes?
What type if known?
Type of deodorant used by the mother?
If none, please state 
Type of deodorant used by the father?
Type of shampoo used by the mother?
Type of hair creme-rinse used by the mother?
How often was finger nail polish applied by the mother? Was this done in a salon or at home?
How often were hair permanents done?
Did the mother color her hair? 
If yes, what type and what color?
Did the mother use a face
"foundation" base-make up?
What type? Creme, powder, etc.
How often was hair spray applied by the mother?  What type?
Did the father ever use any type of hair coloring, creme, tonic or hair spray? Explain
How close to the nearest microwave tower?
estimate distance - feet - miles - etc.
These are metal towers about 100 feet high which are used to transmit phone or cell phone communications.
How close do you live to High Power Lines?
Are any factories in the vicinity of your home? Explain
How often and how long did the patient use a pacifier as a child?
List type of x-rays taken of cancer patient prior to cancer diagnosis (do not list any   x-rays which diagnosed the cancer).
How many ultrasounds were performed on the patient?
Did mother receive anesthesia during the pregnancy (dental, etc.) (not counting during child delivery). Please explain.
What type of anesthesia procedure was used when child was born?  Local, spinal block, general anesthesia, etc.? Please be as specific as possible
Please explain any remodelling done in your home one year before conception up until cancer diagnosis? Painting? Drywall?  Wall Paper? New Carpet
If you answered "yes" to the above question -
How long after remodelling did cancer appear?
How often were skin cream moisturizers used on the mother? What type?
How often were moisturizing skin creams used over the patient? What type?
How often was suntan or sunblock lotion used by mother? List type if known.
How often was suntan or sunblock  lotion put on child before cancer diagnosis?  
Also, list type if known.
How often did child swim in a chlorinated pool?
Please explain if yes.
How close was home to the
nearest trash incinerator?
Was the flavor enhancer ACCENT' ever used on foods? If yes, how often?
Are you aware of any foods eaten regularly which contained monosodium glutamate (MSG)?  These often include flavored potato chips, cheetos type snacks, frozen pizza, soups, etc. List any if you are aware
Alcohol drinking habits of the mother before and during pregnancy?
Amount of alcohol consumed by father
3 months prior to conception?
How much did the child's mother smoke during pregnancy?
How much did the child's father smoke from 3 months prior to conception?
Age of child's first vaccination, and total number of vaccinations received
Following vaccination - did child's behavior change regarding  - mood - personality - noises - sleeping patterns - etc?
Describe any fluoride treatments child received
Vinyl is a soft pliable plastic that has been linked with cancer.  Please list any vinyl sources you are aware of - (example - vinyl cover over mattress for preventing urine spills - vinyl wallpaper in child's room etc.)
If (when) child was under 4 - how often were  fluoride toothpastes used to brush their teeth?
Amount of coffee consumed during pregnancy by mother?
Can you think of any other chemical exposures your child experienced that we did not discuss?
Primary water drank by child -TAP - DISTILLED - bottled SPRING?
Email address for sending results of this study when completed
City and state where cancer was diagnosed
First and Last name of person completing form (optional).
This will help us address you directly if we need to send or ask for help with details of a circumstance
Do you have any suggestions for other questions which you feel should be added or improvements for wording of present questions?

May we contact you by email
if we feel it would help to get more detail on your answers?
yes   no

Thank you,
Dr. Wayne Sinclair, M.D.
Richard W. Pressinger, M.Ed.
Allergy, Asthma, Immunology
Cancer Research Project
Durham, North Carolina

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