Is this a new survey or an update on a previous survey?
New Update on earlier one Unsure

Patient name (first name or code name is fine)

Basic Patient information:

Patient is a Enter Human Dog Cat Ferret Other

Gender : Male or Female

Age Enter 0-5 6-12 13-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

Weight of patient Pounds Kilograms

Cancer Information:

Cancer type : for example, non-small cell lung cancer, breast, prostate etc.
Add any details you wish.


Stage Enter Stage IV Stage III Stage II Stage I Unsure

Sarcoma or carcinoma? Enter Carcinoma Sarcoma Other Not sure why

If there is anything else you wish to share about the cancer, please do so:

DCA and Tumor Response:

For about how long has, or did, the patient take DCA? Enter less than 1 week 2 weeks 3 weeks 1 month 1 1/2 months 2 months 3 months 4 months 5 months 6 plus months

DCA dose. Please describe.

How many times a day did you take DCA? Enter Did not take Once a day Twice a day Three times a day Four or more times

In your opinion, did the DCA work for you?
Yes
No
Not sure
Why or why not?

Tumor response:
Enter No response, tumor grew Mixed response, some tumors grew, others did not respond Tumor stabile Good response, tumor shrank unsure

How do you rate your health compared to when you started DCA?
Enter Much better Somewhat better About the same Somewhat worse Much Worse

Record any comments about the response here:

Caffeine Use:

Does or did the patient drink caffeinated drinks with some regularity while taking DCA?
Please do not confuse de-caffeinated drinks with caffeinated.
Yes
No
Not sure

If the Patient drank caffeinated drinks, what types of caffeinated drinks and how much per day?

Caffeinated Coffee / average number of cups per day Enter 1 cup 2 cups 3 cups 4 cups 5 cups 6 cups 7 cups 8 cups 9 cups 10 or more cups NO coffee drank 1 cup a week 2 cups a week 3 cups a week 4 cups a week 5 cups a week

Caffeinated Black Tea / average number of cups per day Enter 1 cup 2 cups 3 cups 4 cups 5 cups 6 cups 7 cups 8 cups 9 cups 10 cups 11 cups 12 or more cups NO black tea 1 cup a week 2 cups a week 3 cups a week 4 cups a week 5 cups a week

Caffeinated Green Tea / average number of cups per day Enter 1 cup 2 cups 3 cups 4 cups 5 cups 6 cups 7 cups 8 cups 9 cups 10 cups 11 cups 12 or more cups NO green tea 1 cup a week 2 cups a week 3 cups a week 4 cups a week 5 cups a week

Caffeinated Iced Tea / average number of cups per day Enter 1 cup 2 cups 3 cups 4 cups 5 cups 6 cups 7 cups 8 cups 9 cups 10 cups 11 cups 12 or more cups NO green tea 1 cup a week 2 cups a week 3 cups a week 4 cups a week 5 cups a week

Caffeinated Soda / average ounces drank per day. Not all sodas contain caffeine. Please list the brand of soft drink(s) in the comments section. Enter about 8 ounces about 16 ounces about 24 ounces about 32 ounces 40 or more NO sodas 1 soda a week 2 sodas a week 3 sodas a week 4 sodas a week 5 sodas a week

Energy Drink / average ounces drank per day Enter about 8 ounces about 16 ounces about 24 ounces about 32 ounces 40 or more NO Energy drinks One a week Two a week Three a week Four a week Five a week

Do you add milk or cream to your tea or coffee? Yes No Unsure

Other. Give details please. (Note, e.g. that regular Excedrin has caffeine)
:

Comments of Caffeine use:(the brands might be helpful)

Dietary-related questions:

Does the patient take any of these supplements? Please note that this listing does NOT indicate we suggest them. This is to see if we can find any correlations, positive or negative..

Alpha lipoic acid Yes No Unsure

CoQ10 Yes No Unsure

Fish Oil Yes No Unsure

Flaxseed oil Yes No Unsure

Paw Paw Yes No Unsure

Serrapeptase Yes No Unsure

Soy genistein Yes No Unsure

St. John's Wort Yes No Unsure

Valeria Yes No Unsure

Vitamin B1 Yes No Unsure

Vitamin C Yes No Unsure

Vitamin D Yes No Unsure

Vitamin E Yes No Unsure

Magnesium Yes No Unsure

Any other supplements taken?


Is the patient on a Low Fat diet? Yes No Unsure

Chocolate Consumption Enter Does not eat chocolate Eats a small amount of chocolate Eats moderate amounts of chocolate Eats lots of chocolate Unsure

Alcohol Consumption Enter Does not drink alcohol Drinks a little alcohol Drinks moderate amounts of alcohol Drinks a lot of alcohol Unsure

Does the patient eat sweet items made with sugar?
Enter Eats a lot of sweets Eats some sweets Rarely eats sweets Unsure

Meat Consumption
Enter Does not eat meat No red meat, some fish etc Eats a little meat Eats moderate amounts of meat Eats a lot of meat Unsure help

Please list anything notable about the diet or habits of the patient:

Miscellaneous Things:

Are you taking:

Chemotherapy? Yes No Unsure

Radiation? Yes No Unsure

Surgery? yes No Unsure

If any, please describe:

Do you take any of these medications? (this is important)
Nexium (Esomeprazole) Yes No Unsure
Prevacid (Lansoprazole, Zoton, Inhibitol) Yes No Unsure
Prilosec (Omeprazole, Losec, Zegerid) yes No Unsure
Pantoprazole (Protonix, Somac, Pantoloc, Pantozol, Zurcal) Yes No Unsure
Rabeprazole (Rabecid, Aciphex, Pariet) Yes No Unsure
Morphine Yes No Unsure

What medications are being used? Please list:

We have noticed that when caffeine is used with DCA sometimes the patient reports sleepiness, weakness in the legs and less stability in standing. Have you any of those symptoms?
Sleepiness Yes No Unsure
Weakness in legs Yes No Unsure
Stability Yes No Unsure

Please describe any possible side effect issues noted with DCA:


Are you working with a doctor or veterinarian? Enter Yes No Unsure

If the patient is working with a doctor, does the doctor know you are using DCA?
Yes. Doctor is supportive
Yes. Doctor is not supportive
No. Doctor does NOT know
Unsure

Is the patient still taking DCA?
Yes
No
Unsure

If the patient is no longer using DCA, why?

Do we have your permission to post this survey, minus your personal information? We are still debating whether to post the full data or to include only summaries and conclusions. It might help if you let us know your thoughts on this, in the Final Comments box below.
Yes No Unsure

A question completely outside of the original scope of this survey:

If you have breast cancer especially, have you had contact with mice? why
Yes No Unsure

If so, could you give some details, including the nature of the contact, geographical area as specifically as you can, and the species of mouse if you happen to know?

Final Comments?