Are you answering on behalf of yourself or a loved one?
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Myself
A Loved One
If you answered on behalf of a loved one, is the loved one still alive?
Yes
No
Has there been a diagnosis of cancer?
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Yes
No
If Yes, please identify which cancer:
Colon / Colo-rectal
Bladder
Kidney
Liver
Prostate
Lung
Esophageal
Brain
Other
If other, please specify:
What year was the cancer diagnosis?
Use / Ingestion of Zantac prior to cancer diagnosis?
Yes
No
If yes, approximately how many months prior to cancer diagnosis was there consistent use of Zantac?
Age at the time of diagnosis?
Any prior history of cancer in your or your family?
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Yes
No
If yes, please state which type of cancer:
Name
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Phone
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Email
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