Form Not Assigned Not Assigned Child Topical Module

Child Component of the Complementary and Alternative Medicine Supplement

The next questions are about any health conditions [CHILD] may have.

ADDED CONDITIONS TO CHILD CORE CHS SECTION:

DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [child’s name] had ... [READ LIST]

... Lung or breathing problems, other than asthma

... Cancer

... Neurological problems

... Urinary problems including urinary tract infection

... Gum disease

... Influenza or pneumonia

... Sinusitis

... Strep throat or tonsillitis

... Depression

... Phobia

DURING THE PAST 12 MONTHS, Has [child’s name] had ...

... Allergies other than hay fever, respiratory allergies, food or digestive allergies, or skin

allergies

... Recurring headache, other than migraine

... Abdominal pain

... Back or neck pain

... Other chronic pain

... Fatigue or lack of energy

... Fever

... Head or chest cold

... Sore throat other than strep or tonsillitis

... Problems with Acid reflux or heartburn

... Nausea and/or vomiting

... Recurring Constipation

... Insomnia or trouble sleeping

... Problems with being overweight

... Severe Acne

... Warts

... Skin problems other than eczema, acne, or warts

... Anxiety or Stress

... Incontinence, including bed wetting

... Menstrual problems such as heavy bleeding,

bothersome cramping, or premenstrual syndrome (also called PMS)

Now I am going to ask you about some health services [child’s name] may have used. First I will ask you about some specific services for which [child’s name] would have seen a practitioner. Then I will ask you about some other health practices [child’s name] may have done on his/her own.

Modalities that Require Practitioner

SHOW HAND CARD (PRACTITIONER MODALITIES)

PRT.1 DURING THE PAST 12 MONTHS, did [child’s name] see a provider or practitioner for any of the following therapies? Please say yes or no to each.

(1) Acupuncture yes no

(2) Ayurveda yes no

(3) Biofeedback yes no

(4) Chelation Therapy yes no

(5) Chiropractic or Osteopathic Manipulation yes no

(6) Energy Healing Therapy yes no

(7) Hypnosis yes no

(8) Massage yes no

(9) Naturopathy yes no

PRT.2 During the past 12 months, did [child] use (modality) for a specific health problem or condition?

(1) Yes (next question)

(2) No (next modality)

PRT.3 During the past 12 months, for what health problems or conditions did [child] use [modality]?

_______________________________

_______________________________

_______________________________

_______________________________

[Hand Card]

TRD.1 DURING THE PAST 12 MONTHS, did [child’s name] see any of the following practitioners?

(1) Curandera

(2) Espiritistas

(3) Hierbero or Yerbera

(4) Shaman

(5) Botanica

(6) Native American Healer / Medicine Man

(7) Sobador

[If no to all, goto next modality]

[IF MORE THAN ONE YES in TRD.1, ASK TRD.1a; ELSE GO TO TRD.2]

TRD.1a During the past 12 months, which practitioner {fill practitioners from TRD.1} did your child use the most?

_____________________ [TECHNIQUE]

TRD.2 During the past 12 months, did [child] see {fill: practitioner from TRD.1 or TRD.1a} for a specific health problem or condition?

(1) Yes (next question)

(2) No (next modality)

TRD.3 During the past 12 months, for what health problems or conditions did [child] see {fill: practitioner from TRD.1a}?

_______________________________

_______________________________

_______________________________

_______________________________

MOV.1 DURING THE PAST 12 MONTHS, did [child’s name] see a practitioner or teacher for any of the following? Please say yes or no to each.

(note: add pronunciation guide)

(1) Feldenkreis yes no

(2) Alexander Technique yes no

(3) Pilates yes no

(4) Trager Psychophysical Integration yes no

[If no to all, goto next modality]

[IF MORE THAN ONE YES in MOV.1, ASK MOV.1a; ELSE GO TO MOV.2]

MOV.1a During the past 12 months, which practitioner or teacher {fill from MOV1} did your child use the most?

_____________________ [TECHNIQUE]

MOV.2 During the past 12 months, did [child] use {fill: type of movement therapy from MOV.1 or MOV.1a} for a specific health problem or condition?

(1) Yes (next question)

(2) No (next modality)

MOV.3 During the past 12 months, for what health problems or conditions did [child] use {fill: type of movement therapy }?

_______________________________

_______________________________

_______________________________

_______________________________

HERBS and Other Non-vitamin/non-mineral Dietary Supplements

Now I am going to ask you about some additional health practices for your child. The first practice I’ll ask about is herbal supplements, then later I’ll ask about vitamins and minerals.

People use herbs and other non-vitamin supplements for their children for a variety of reasons. By herbal supplement we mean pills, capsules or tablets that have been labeled as a dietary supplement. This does NOT include drinking herbal or green tea.

SHOW HAND CARD HRB#1 (HERB LIST)

HRB.1 DURING THE PAST 12 MONTHS, has [child] taken any herbal supplements listed on this card?

(1) Yes (2) No (next modality)

HRB.2 DURING THE PAST 30 DAYS did [child] take any herbal supplements listed on the card?

Yes

No (GO TO NEXT MODALITY)

HRB.3 Please tell me which supplements [child] took in the past 30 days. If he/she took more than one herb in a single supplement, select “combination herb pill.” [MARK ALL THAT APPLY]

________________________

________________________

________________________

________________________

________________________

________________________

[IF NONE GO TO NEXT MODALITY - VITAMINS; IF MORE THAN 2 ASK HRB.4, OTHERWISE GOTO HRB.5 - ASK REST OF SECTION FOR EACH HERB]

HRB.4 Which two of these herbal supplements did [child] take the most in the past 30 days?

________________________

________________________

________________________

HRB.5 Did [child] take [herb] to treat a specific health problem or condition?

Yes (next question)

No (HRB.7)

HRB.6 For what specific health problem or conditions did [child] take [herb]?

____________________________

____________________________

____________________________

____________________________

HRB.7 Did [child] take natural herbs to improve athletic or sports performance?

Yes

No (next herb or next modality)

HRB.8 Which herbs did [child] take to improve athletic or sports performance?

Yes (next herb or next modality)

No (next herb or next modality)

VITAMINS

The next questions are about any vitamins and minerals [child] may take.

SHOW HAND CARD VIT#1 (VITAMIN LIST)

VIT.1 Thinking of the examples on this card, DURING THE PAST 12 MONTHS, did [child] take any vitamins or minerals?

(1) Yes (2) No (next modality)

VIT.2 DURING THE PAST 30 DAYS did [child] take any vitamins or minerals?

yes

no (GO TO NEXT MODALITY)

VIT.3 Please tell me which items on this list [child] took in the past 30 days. If he/she takes a multi-vitamin or mineral, include it as one supplement.

________________________

________________________

________________________

________________________

________________________

________________________

[If more than 3 ask VIT.4 else goto VIT.5]

VIT.4 Which two of these vitamin & minerals did [child] take the most in the past 30 days?

________________________

________________________

________________________

VIT.5 Did [child] take [vitamin/mineral] to treat a specific health problem or condition?

Yes (next question)

No (next vitamin or VIT.7)

VIT.6 For what specific health problem or conditions did [child’s name] take [vitamin/mineral]?

____________________________

____________________________

____________________________

____________________________

[next vitamin or VIT.7]

VIT.7 Did [child] take any vitamins or minerals to improve athletic or sports performance?

Yes

No (next modality)

VIT.8 Which vitamins or minerals did [child] take to improve athletic or sports performance?

____________________________

____________________________

____________________________

____________________________

Self-Practiced Modalities

HOMEOPATHIC TREATMENT

People who use homeopathy to treat health problems take small pills or drops that are placed under the tongue. These pills or drops are often prescribed by practitioners of homeopathy.

HOM.1 DURING THE PAST 12 MONTHS did [child’s name] use homeopathic treatment?

(1) Yes (next question)

(2) No (GO TO NEXT MODALITY - DIETS)

HOM.2 DURING THE PAST 12 MONTHS, did [child] use homeopathic treatment for a specific health problem or condition?

(1) Yes (next question)

(2) No (next modality)

HOM.3 During the past 12 months, for what health problems or conditions did [child] use homeopathic treatment?

__________________________________

__________________________________

__________________________________

__________________________________

SPECIAL DIETS

SHOW HAND CARD (SPECIAL DIETS)

DIT.1 DURING THE PAST 12 MONTHS did [child] use any of the following special diets for two weeks or more for health reasons? Please say yes or no to each.

(1) Vegetarian (for health reasons) YES NO

(2) Macrobiotic YES NO

(3) Atkins YES NO

(4) Pritikin YES NO

(5) Ornish YES NO

(6) Zone YES NO

(7) South Beach YES NO

[IF NO TO ALL, GO TO NEXT SECTION – YOGA]

DIT.2 During the past 12 months, did [child] use [diets mentioned in DIT.1] to treat a specific health problem or condition other than weight control or weight loss?

(1) Yes (next question)

(2) No (next modality)

DIT.3 During the past 12 months, for what health problems or conditions did [child] use [diets mentioned in DIT.1]?

___________________________

___________________________

___________________________

___________________________

DIT.4 Did {child} use this diet for weight control or weight loss?

(1) Yes

(2) No

YOGA/TAI CHI/QI GONG

YOG.1 DURING THE PAST 12 MONTHS did [child’s name] practice any of the following? Please say yes or no to each.

(1) Yoga YES NO

(2) Tai Chi (TIE-CHEE) YES NO

(3) Qi Gong (CHEE-KUNG) YES NO

[IF NO TO ALL, GO TO NEXT MODALITY – RELAXATION TECHNIQUES]

YOG.2 During the past 12 months, did [child] practice (exercises mentioned in YOG.1) for a specific health problem or condition?

(1) Yes (next question)

(2) No (next modality)

YOG.3 During the past 12 months, for what health problems or conditions did [child] practice (exercises mentioned in YOG.1)?

_______________________________

_______________________________

_______________________________

_______________________________

RELAXATION and STRESS MANAGEMENT TECHNIQUES

REL.1 DURING THE PAST 12 MONTHS, did [child] use any of the following relaxation or stress management techniques? Please say yes or no to each.

(1) Meditation YES NO

(2) Guided imagery YES NO

(3) Progressive relaxation YES NO

(4) Deep breathing exercises YES NO

(5) Support group meeting YES NO

(6) Stress management class YES NO

[IF NO TO ALL, GO TO NEXT MODALITY – PRAYER]

REL.2 During the past 12 months, did [child] use [relaxation techniques mentioned in REL.1] for a specific health problem or condition?

(1) Yes (next question)

(2) No (next modality)

REL.3 During the past 12 months, for what health problems or conditions did [child] use [relaxation techniques mentioned in REL.1]?

____________________________________

____________________________________

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2007 NHIS Alternative Health Supplement - 3 -