Are you a patient, friend or family member of a patient, or a physician or medical expert?	- Please Select - Patient Friend Family Member Physician Medical Expert
Have you, or someone you know, lived in Liberia at any time and been diagnosed with cancer (any kind) in the past (10, 15?) years?	Please Select Yes No
What type(s) of Cancer were you/they diagnosed with?
What other part(s) of the body are/were affected by cancer?
Were there any symptoms of ill health prior to diagnosis?	- Please Select - Yes No Don't Know
What where the symptoms of illness if any?
Were they diagnose in West Africa or in the US, Europe, Canada or Asia?
What year did the individual enter the US?
Where did the patient live during the (10, 15?) years prior to the time of diagnosis, and for how long? (We usually start of in one place and end up in another. Please list all cities you can remember?
When were they last immunize and where?
What type of immunization did they have? (Don't know is acceptable)
What was the individual basic diet? Example (African food or American food)? What was the individual diet prior to diagnosis? What was the individual diet after diagnosis ? What was the individual diet prior to changing residence ? What was the individual diet after changing residence ?
Did they smoke?	Yes No Never Don't Know How long?
Specify other risk factors?	Please select as many as applies On Medication Exposure to Asbestos Experience Late Menopause Family History Other
Gender?	Gender Male Female
Age at Diagnosis
Age at Death
Any other comments you may have:

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