Research Survey | We Are With You Care

Section 1 of 12 · Respondent Info

Who is this survey about?

This survey is open to all ages — not just children. Parents can fill this out on behalf of their child.

This survey is about: *

First Name (optional)

Date of Birth

Current Age *

Biological Sex at Birth

Birth State / Country *

Birth City / Town

Current City / State

Birth Weight (if known)

Complications at birth?

Was the child breastfed?

Section 2 of 12 · Cancer Diagnosis

Cancer Diagnosis Details

Help us understand the type and timeline. If the person has not been diagnosed, fill in what's known.

Has a cancer diagnosis been received? *

Type of Cancer *

Age at Diagnosis

Diagnosis Date (approx.)

Stage at Diagnosis

First symptoms noticed *

How long from first symptoms to official diagnosis?

Current treatment status *

Section 3 of 12 · Family & Genetic History

Family & Genetic History

Family history is one of the most critical data points in cancer research.

Family history of cancer (select all that apply)

Father's side Mother's side Siblings Paternal grandparents Maternal grandparents Aunts / Uncles No known family history

Which cancer types and on which side?

Known genetic mutations or hereditary syndromes

Mother's age at birth

Father's age at birth

Ethnicity / Ancestry

Did the mother smoke, drink alcohol, or use substances during pregnancy?

Number of siblings (biological)

Section 4 of 12 · Diet & Nutrition

Diet & Nutrition Habits

What was consumed regularly — from infancy to now — may reveal important research patterns.

Infant formula used (if applicable)

Primary milk / dairy consumed regularly

Toothpaste brand used (exact brand if possible)

Any food allergies or intolerances?

Regular supplements or vitamins?

Primary diet / eating style

How often is food prepared at home vs. eating out?

Alcohol consumption (if adult / self)

Section 5 of 12 · Personal Care & Cosmetics

Personal Care Products & Cosmetics

Studies link certain chemicals in personal care products (parabens, phthalates, formaldehyde, etc.) to cancer risk. Be as specific with brand names as possible — this is one of our most important research areas.

📌 Tip: Check your bathroom for actual brand names. Include the product type if you're not sure of the brand (e.g. "store brand shampoo", "fragrance-free lotion").

Shampoo brand & type

Conditioner brand & type

Body wash / soap brand

Face wash / cleanser brand

Moisturizer / lotion brand

Sunscreen brand & SPF (if used regularly)

Deodorant / antiperspirant brand & type

Toothpaste brand (exact)

Hair styling products used regularly

Hair spray Gel / mousse Hair dye / color treatments Chemical relaxer / perm / keratin Dry shampoo Heat protectant spray None / minimal

Cosmetics brand(s) used most frequently

How often are personal care products described as "natural", "organic", or "fragrance-free" chosen?

Section 6 of 12 · Home Environment

Home Environment & Cleaning Products

Chemical exposures in the home — from cleaners to pesticides — are a major area of cancer research.

Type of home / housing

Water source at home

Laundry detergent brand & type

Did anyone in the household smoke indoors?

Proximity to environmental hazards

Type of cooking surfaces / cookware used regularly

Non-stick pans (Teflon/PTFE) Stainless steel Cast iron Ceramic-coated cookware Aluminum pots/pans Plastic containers heated in microwave Plastic water bottles (regular use)

Section 7 of 12 · Clothing & Daily Lifestyle

Clothing, Activities & Daily Habits

Textile chemicals, physical activity, and sleep patterns are all areas of active research.

Primary clothing materials worn most days (check all that apply)

100% Cotton Organic cotton Synthetic (polyester / nylon / spandex) Flame-retardant sleepwear (children's) Wool Bamboo / rayon / viscose Linen Mixed / blend — varies

How often is new (unwashed) clothing worn directly?

Average daily screen time (TV, phone, tablet, computer)

Physical activity level

Average nightly sleep duration

Occupation / school environment (potential exposures)

Pets in the home (select all that apply)

Tobacco or nicotine use (personal — adults)

Section 8 of 12 · Medical History

Medical History & Exposures

Past medical events, medications, and radiation exposures help identify potential triggering factors.

Vaccination history

Frequency of antibiotic use before diagnosis

Long-term medications taken (1+ year)

Radiation exposure history (medical imaging)

Notable infections or illnesses before diagnosis

Has the person ever had hormonal / reproductive health issues?

Section 9 of 12 · Mental Health & Stress

Mental Health & Stress Levels

Chronic stress and mental health affect immune function. This data helps us understand the full picture.

Overall stress level in the years before diagnosis

Major life stressors experienced before diagnosis (check all that apply)

Death of close family member or friend Divorce / parental separation Significant financial hardship Trauma or abuse (physical / emotional) Job loss / unemployment Frequent moves / housing instability Bullying or social exclusion None significant

History of diagnosed mental health conditions

Anxiety disorder Depression PTSD Bipolar disorder Eating disorder None diagnosed

Access to mental health support

Section 10 of 12 · Geographic & Socioeconomic Factors

Geographic & Socioeconomic Context

Where people live and access to healthcare can significantly influence cancer outcomes. All ranges are approximate.

Geographic region where the person primarily grew up

Urban vs. rural environment most of life

Approximate annual household income

Health insurance status at time of diagnosis

How far from the nearest major cancer treatment center?

Highest level of education completed (parent / guardian if child)

Section 11 of 12 · Early Life & Additional Factors

Early Life, School & Additional Exposures

Early life exposures and school environments contribute additional data points to our research.

Childcare / early education type

Type of school building (if relevant)

Any known toxic chemical exposures (check all that apply)

Lead paint exposure (pre-1978 home) Asbestos exposure Benzene exposure (fuel, solvents) Formaldehyde (new furniture, renovations) PFAS / "forever chemicals" (water, nonstick) Heavy metal exposure (mercury, arsenic) Radon detected in home Significant mold in home None known

Sun exposure habits

How would you rate overall air quality in your area?

Any recent home renovations during childhood / pre-diagnosis?

How often were flame-retardant treated products used? (furniture, mattresses, car seats)

Section 12 of 12 · Contact & Consent

Final Step — Contact & Consent

Your contact info is optional and only used if we need to follow up. Consent to use anonymized data for research is required.

Your Name (optional)

Email (optional)

How did you hear about this survey?

Anything else you'd like our research team to know?

By submitting, your responses are stored securely and only ever shared in aggregated, anonymized form with research partners. We never sell your data. You may request deletion at any time by emailing support@wearewithyoucare.org.

I consent to my anonymized responses being used for cancer research and education. *

Thank You

Your responses have been received and will help our research team understand cancer patterns across all ages. Every data point matters. We are with you.

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