Form 1 survey

OMB No. 0925-0530-03

Exp. Date 10/31/2010

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Bethesda, MD 20892-7974, ATTN: PRA (0925-0530). Do not return the completed form to this address.

Complementary and Alternative Medicine (CAM) Use

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CAM is a group of diverse medical and health care systems, practices, and products that are not currently considered to be part of conventional medicine. Examples of CAM include such products and practices as herbal supplements, meditation, chiropractic manipulation, and acupuncture.

e’re interested in learning about how you as a health care professional communicate with your patients about CAM use. Your responses will be confidential and anonymous (see http://nccam.nih.gov/tools/privacy.htm). Thank you for sharing your thoughts.

1. Do you ask patients about their CAM use? Yes No

2. How important do you think it is to discuss CAM therapy use with your patients? (Circle one response.)

   1. Not at all important

   2. Not too important

   3. Somewhat important

   4. Very important

3. Please estimate the percentage of your patients with whom you discuss complementary and alternative medicine.

a. 0-25%

b. 26-50%

c. 51-75%

d. 76-100%

4. Do your patient history forms include a question about CAM use? ­­­­­­­­­­­­­­­­­­­ Yes No

5. When you discuss CAM use, who usually initiates the conversation?

1. Me/My staff

2. Patients

3. N/A

6. How comfortable are you discussing CAM with patients?

1. Very comfortable

2. Somewhat comfortable

3. Somewhat uncomfortable

4. Very uncomfortable

7. Do any of the following keep you from talking more often with your patients about CAM? (Select all that apply.)

1. Not enough time during office visit.

2. It’s not a high priority for me.

3. I don’t want to encourage CAM use.

4. I don’t know enough about CAM to feel comfortable discussing it.

5. Other:______________

8. How familiar are you with the National Institutes of Health’s National Center of Complementary and Alternative Medicine’s Time to Talk materials? [Show graphic of the toolkit]

1. Have never seen them before

2. Have glanced at them

3. Are aware of the materials, but don’t use them in my practice

4. Have read over the materials and use them in my practice

Please look over the materials and then answer the following questions.

9. Please take a moment to review the Ask fact sheet. Then circle the number that best represents your response to each of the following statements.

	Strongly Agree				Strongly Disagree
The information in the fact sheet would be helpful for me and my staff.	1	2	3	4	5
After reading this fact sheet, I am encouraged to bring up CAM use with my patients.	1	2	3	4	5
I would make this fact sheet available to my staff.	1	2	3	4	5

10. Please take a moment to review the Tell fact sheet. Then circle the number that best represents your response to each of the following statements.

	Strongly Agree				Strongly Disagree
The fact sheet is easy for patients to understand.	1	2	3	4	5
The information in the fact sheet is helpful for patients.	1	2	3	4	5
After reading this fact sheet, patients will be encouraged to bring up CAM use with me.	1	2	3	4	5
I would make these fact sheets available to my patients	1	2	3	4	5

11. Please take a moment to review the wallet card. Then circle the number that best represents your response to each of the following statements.

	Strongly Agree				Strongly Disagree
The wallet is easy for patients to understand and complete.	1	2	3	4	5
By using this wallet card, patients will be encouraged to bring up CAM use with me.	1	2	3	4	5
I would make these wallet cards available to my patients	1	2	3	4	5

12. Having looked at the materials now, how likely are you to incorporate the Time to Talk materials into your practice?

1. Very likely

2. Somewhat likely

3. Neutral

4. Somewhat unlikely

5. Very unlikely

If you selected unlikely, please state why:

_______________________________________________________________________________

13. What other information or materials would help you in discussing CAM use with your patients?

________________________________________________________________________________

________________________________________________________________________________

_____________________________________________________________­­­­­­­­­­­___________________

14. How often do you consult each of the following sources for information on conventional medicine or complementary and alternative medicine?

	Once a year or never	At least two times a year; less than monthly	At least monthly; less than weekly	At least weekly; less than daily	Daily	Please list specific websites or titles that you consult
Internet	1	2	3	4	5
Medical journals	1	2	3	4	5
Newsletters	1	2	3	4	5
Other	1	2	3	4	5

15. Are there specific Web sites or other sources you find particularly useful in obtaining information about CAM?

a. No

b. Yes (Please list names: _________________________________________________________________)

Please complete the following demographic questions:

16. Please circle your gender: Male Female

17. Please circle your ethnicity and race:

Ethnicity:

• Hispanic or Latino

• Not Hispanic or Latino

Race:

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

Thank you for helping us by completing this questionnaire.