Form #1 Form #1 Short CAM Questionnaire

OMB No 0925-0530

Exp. Date 10/31/2010

Complementary and Alternative Medicine Use

We’re interested in learning about how and when you and your health care providers discuss complementary and alternative medicine (CAM). Your responses will be confidential and anonymous (see http://nccam.nih.gov/tools/privacy.htm). Thank you for sharing your thoughts.

Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0530). Do not return the completed form to this address.

Complementary and alternative medicine (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 or taught in U.S. medical schools. Examples of CAM include such products and practices as herbal supplements, meditation, chiropractic manipulation, and acupuncture.

1. Do you ever use any of the following types of complementary and alternative medicine (CAM)? (Circle all that apply)

1. Herbal products or dietary supplements

2. Massage therapy, chiropractic manipulation, or other bodywork

3. Mind/body practices, including hypnosis, meditation

4. Energy therapies, including magnets and reiki

5. Naturopathy, acupuncture, or homeopathy

6. Other

7. I have never used any type of complementary and alternative medicine

2. How important do you think it is to discuss CAM therapies you use with your health care providers? (Circle one response.)

1. Not at all important

2. Not too important

3. Somewhat important

4. Very important

3. Have you ever discussed CAM with any of your health care providers?

1. Yes

2. No

3a. If no, which of the following are reasons why you did not discuss CAM? (Select all that apply)

1. Didn’t know I should

2. Didn’t think of it

3. Not enough time during office visit

4. My health care provider never asked

5. I don’t think my health care provider knows about the topic

6. My health care provider would have been dismissive or told me not to do it

7. I wasn’t using any CAM therapy at the time of the visit

8. Other

3b. If yes, who first brought up the subject?

1. I did

2. My health care provider

3. Relative/friend

4. Other

4. How comfortable are you bringing up CAM with your health care providers?

1. Very uncomfortable

2. Somewhat uncomfortable

3. Neutral

4. Somewhat comfortable

5. Very comfortable

5. What is your age?

1. 50-59

2. 60-69

3. 70-79

4. 80-89

5. 90 or over

6. Are you:

1. Female

2. Male

7. Please take a moment to review the one-page fact sheet. Then circle the number that best represents your response to each of the following statements.

The fact sheet was…	Easy to understand 1	2	3	4	Hard to understand 5
The information in the fact sheet was…	Very useful 1	2	3	4	Not at all useful 5
After reading this fact sheet, I am ___ to bring up CAM use with my health care providers.	Much more likely 1	2	3	4	Much less likely 5
The fact sheet’s design, colors and layout are	Very attractive 1	2	3	4	Very unattractive 5
The type size is…	Very easy for me to read 1	2	3	4	Very difficult for me to read 5

9. What additional information, if any, would you like to have?

10. Please review the wallet card and respond to the following statements.

The instructions for completing the wallet card were…	Easy to understand 1	2	3	4	Hard to understand 5
I ___ use the wallet card to track my medication use, including any CAM practices and supplements.	Definitely will 1	2	3	4	Definitely will not 5
The wallet card’s design, colors and layout are	Very attractive 1	2	3	4	Very unattractive 5
The type size is…	Very easy for me to read 1	2	3	4	Very difficult for me to read 5
The space on the wallet card to fill in my information is	Ample 1	2	3	4	Insufficient

11. What additional information, if any, would you like to have or to be able to record on the wallet card?

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