Attachment 1- Instrument
The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used only for statistical purposes by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Public reporting burden for this collection of information is estimated to average 60 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).
OMB #0920-0222; Expiration Date: 03/31/2013
Note to reviewer: Testing sponsors have asked that we probe mainly on the items that are listed as "new." Also, depending on how recruitment works out, we will likely focus on probing on only some sections of the instrument with each respondent. In other words, if we find that a respondent has used multiple CAM modalities, we will focus on only 1 or 2 of those so we can get through the instrument in a reasonable amount of time.
Child Component of the Complementary and Alternative Medicine Supplement
The next questions are about any health conditions [CHILD] may have.
CONDITIONS
Note: age skips to be added after consulting with clinician
CON.1 DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [child’s name] had ... [READ LIST]
... [new]hypertension also called high blood pressure (age skip?)
Was child told on two or more different visits that he/she
Had hypertension, also called high blood pressure?
... [new]High cholesterol
... Lung or breathing problems, other than asthma
... Cancer
... Neurological problems
... Urinary problems such as incontinence, frequent
Or slow urination or infections
... Influenza or pneumonia
... Depression
... [new] inflammatory bowel disease, irritable bowel, Crohn’s
Disease, ulcerative colitis, or constipation
severe enough to require medication
Which of these did child have?
... Sinusitis
... [new]Other infectious diseases and problems of the immune
system
... [new] follow up to sickle cell anemia: During the past 12
Months, have you had pain due to sickle cell anemia?
... Strep throat or tonsillitis
... sore throat other than Strep or tonsillitis
CON.2 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
CON.3 [new] During the past 30 days, has child had any symptoms of….
pain, aching, or stiffness in or around a joint?
... neck pain
... [new] low back pain
... [new] facial ache or pain in the jaw muscles or the joint
In front of the ear
... [new] Other muscle or bone pain
... Other chronic pain
... Fatigue or lack of energy
... Fever
... Head or chest cold
... [new] stomach or intestinal illness with vomiting or
Diarrhea that started during those two weeks?
... Sore throat
... Problems with Acid reflux or heartburn
... [new] Regular headaches
... [new] severe headache or migraine
... [new] any severe sprains or strains
... [new] Dental pain
... Problems with being overweight
... [new]Skin problems other than eczema
... [new]Regularly had insomnia or trouble sleeping
... [new]Regularly had excessive sleepiness during the day
... [new]Frequent Anxiety
... [new]Frequent Stress
... [girls 10+] Menstrual problems such as heavy bleeding,
bothersome cramping, or prementrual syndrome
(also called PMS)
... [new][girls 10+] gynecologic problems such as vaginal
infection
Adult Component of the Complementary and Alternative Medicine Supplement
CONDITIONS
CON.1 Have you EVER been told by a doctor or other health professional that you had ... [READ LIST]
... High cholesterol
... Phobia or fears
... Influenza or pneumonia
... Poor circulation in your legs
... Urinary problems such as incontinence, frequent
Or slow urination or infections
... Attention Deficit Hyperactivity Disorder (ADHD) or
Attention Deficit Disorder (ADD)?
... Bipolar Disorder
... Depression
... Mania or psychosis
... Schizophrenia
... Seizures
... Inflammatory bowel disease, irritable bowel, Crohn’s
Disease, ulcerative colitis, or constipation
severe enough to require medication
Which of these did you have in the past 12 months?
... [new] Sickle Cell Anemia
... [new] follow up to sickle cell anemia: During the past 12
Months, have you had pain due to sickle cell anemia?
... [new] Other infectious diseases and problems of the immune
System
... [new] Strep throat or tonsillitis
... [new] sore throat other than Strep or tonsillitis
CON.1a [FOR ANY YES RESPONSE ASK]: During the past 12 months, have you had [condition mentioned above]...
CON.2 During the past 12 months, have you had….
... Problems with Acid reflux or heartburn
... [new] nausea and/or vomiting
... Recurring headache, other than migraine
... [new] Abdominal pain
... Memory loss or loss of other cognitive functions
... Any severe sprains or strains
... Dental pain
... Excessive use of alcohol or tobacco
... Substance abuse, other than alcohol or tobacco
... [new] problems with being overweight
... Skin problems
... Regularly had insomnia or trouble sleeping
... Regularly had insomnia or trouble slee
... Regularly had excessive sleepiness during the day
... Been frequently anxious
... [new] Frequent Stress
... [new] Fever
... [new] Head or chest cold
... [new] Any kind of respiratory allergy
... [new] Any kind of digestive allergy
... [new] Eczema or any kind of skin allergy
... [new] Allergies other than hay fever, respiratory
Allergies, food or digestive allergies, or skin
Allergies.
... [new] Other muscle or bone pain
... [new] Other chronic pain
... [new] Fatigue or lack of energy
... [new] Other neurological problem
... [women 18-55]Any menstrual problems such as heavy bleeding,
Bothersome Cramping, or pre-menstrual syndrome (also
called PMS)
... [women 45-57]Any menopausal problems such as hot
flashes,night sweats,Or other menopausal symptoms.
... [all women]Any gynecologic problems such as
vaginal infection, uterine Fibroids, or infertility.
... [men 40+]Any men’s health problems such as prostate
trouble,or impotence?
Complementary and Alternative Medicine Supplement
Now I am going to ask you about some health services you may have used. First I will ask you about some services for which you would have seen a practitioner. Then I will ask you about some other health practices you may have done on your own.
Modalities that Require Practitioner
PRT.1 Have you EVER seen a provider or practitioner for any of the following therapies for yourself? Please say yes or no to each.
(1) Acupuncture yes no
(2) Ayurveda yes no
(3) Biofeedback yes no
(4) Chelation (key-LAY-shun) Therapy yes no
(5) Chiropractic (kye-row-PRAK-tik) or Osteopathic Manipulation yes no
(6) Energy Healing Therapy yes no
(7) Hypnosis yes no
(8) Massage yes no
(9) Naturopathy (nay-chur-AH-puh-thee) yes no
[IF NO TO ALL, GO TO Traditional healers]
PRT.2 DURING THE PAST 12 MONTHS, did you see a practitioner for (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY )
[NEW]
PRT.3 Do you currently use [modality] more, less, or about the same as you did one year ago?
1) More
2) Less
3) About the same
[NEW]
PRT.4 Compared to the past 12 months, do you plan to use [modality] more, less, or about the same during the next 12 months?
1) More
2) Less
3) About the same
[NEW]
PRT.5 (Ask this for respondents who report having health insurance in core, else goto PRT.11)
During the past 12 months, were any of the costs of using (modality) covered by health insurance?
1) Yes (goto PRT.7)
2) No (goto PRT.11)
3) There was no cost for[modality](goto PRT.6)
[NEW]
PRT.6 During the past 12 months, how many times did you see a practitioner for (modality) with no costs?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.7 During the past 12 months, did your health insurance limit the number of visits to a practitioner or the dollar amount covered for (modality)?
1) Yes (goto PRT.7a)
2) No (goto PRT.9)
[NEW]
PRT.7a Which of these did your health insurance limit: the number of visits, the dollar amount, or both?
1) number of visits (PRT.8)
2) dollar amount (PRT.8a)
3) both (PRT.8)
[NEW]
PRT.8 During the past 12 months, how many visits to a practitioner for (modality) were covered by health insurance?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 marked in PRT.7a, else goto PRT.9)
PRT.8a During the past 12 months, what dollar amount did your health insurance cover for (modality)?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW]
PRT.9 How much was your co-payment per visit to a practitioner for (modality) {fill for yes to PRT.7: for visits covered by insurance}?
$ __________________ (if #1 to PRT.7 goto PRT.10 else goto PRT.11)
[NEW]
PRT.10 During the past 12 months, did you see a practitioner for (modality) more than was covered by health insurance?
1) Yes
2) No
[NEW]
PRT.11 During the past 12 months, how many times did you see a practitioner for (modality) {if yes to PRT.10 fill: that was not covered by health insurance}?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 checked in PRT.7a, otherwise goto PRT.12)
PRT.11a During the past 12 months, did you spend more for (modality) than was covered by health insurance?
1) Yes (PRT.11b)
2) No (PRT.12)
[NEW]
PRT.11b During the past 12 months, how much more did you spend for (modality) than was covered by your health insurance?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW] (If no to PRT.7 skip this and goto PRT.13)
PRT.12 On average, how much did you pay out-of-pocket for each visit to a practitioner for [modality] {if yes to PRT.10 fill: that was not covered by insurance}?
$ __________________
$0-$499 *Enter 500 for $500 or more
[NEW]
PRT.13 During the past 12 months, did you buy a self-help book or other materials such as a DVD, CD, or Video to learn about (modality)?
(1) Yes (goto PRT.14)
(2) No (goto PRT.15)
[NEW]
PRT.14 How much did you pay for these materials?
$ ________________________
[NEW]
PRT.15 During the past 12 months, did you use [modality] for any of these reasons? Please say yes or no to each.
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
Medical treatments were not helping you
Medical treatments were too expensive
[modality] combined with medical treatments would help you
To stay healthy
You thought it would be interesting to try [modality]
To improve your energy
To Improve your immune function
To improve your physical performance
To improve your athletic or sports performance
To improve your sexual performance
To improve your concentration
To improve your memory
To improve your flexibility
To improve your muscle strength
Because [modality] was recommended by a medical doctor
Because [modality] was recommended by family, friends, or co-workers
Because the practitioner spends more time with you than medical doctors
Because prescription or over-the-counter drugs are too expensive
Because you can do [modality] on your own
Because you do not want to take prescription medication
Because [modality] is natural
Because [modality] focuses on the entire body and not just one part
Because the practitioner treats your entire body and not just one part
Because you wanted to try something different
Because using [modality] is how I was raised
[NEW]
PRT.17 Thinking about your use of [modality], please tell me if any of these statements are true for you. Please say yes or no to each.
Using [modality] has given you a sense of control over your health?
Using [modality] has helped you to relax?
Using [modality] has helped you to reduce your stress level?
Using [modality] has motivated you to eat healthier?
4a. In what ways are you eating healthier? Say yes or no to each.
Eating more organic foods
Eating more fruits and vegetables
Eating more fish
Eating less saturated fats or trans fats
Eating less processed sugar or less foods make with corn syrup
Eating less red meat
Eating fewer calories
Using [modality] has motivated you to cut back or stop drinking alcohol?
(6)Using [modality] has motivated you to cut back or stop smoking cigarettes, cigars, or pipes?
(7) Using [modality] has motivated you to exercise more regularly?
(8)Using [modality] has improved your overall health and made you feel better?
(9)Using [modality] has given you more hope for the future?
(10)Using [modality] has increased your ability to focus?
(11)Using [modality] has made you feel better emotionally?
(12)Using [modality] has made it easier to cope with health problems?
(13)Using [modality] has improved your outlook on life?
(14)Using [modality] has improved your relationships with others?
(15)Using [modality] has improved your self-confidence?
[NEW]
PRT.18 Of the following reasons, which was the most important reason for using [modality]? (display if more than one of (1,2,3) chosen in question PRT.16 above)
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
(ask if 1,2, or 3 chosen in question PRT.16)
[NEW]
PRT.19 For what health problems or conditions did you use [modality] [to keep from getting/to prevent another occurance/to treat or cure]?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.20; else go to PRT.21]
PRT.20 For which ONE of these health conditions did you use (modality) the most?
_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using modality.
PRT.21 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[2002 Q.]
PRT.22 How much do you think [modality] helped your [condition]? Would you say a great deal, some, only a little, or not at all?
A great deal
Some
Only a little
Not at all
[2002 Q.]
PRT.23 NEW During the past 12 months, how important was your use of [modality] in maintaining your health and well-being? Would you say very important, somewhat important, slightly important, or not at all important?
Very important
Somewhat important
Slightly important
Not at all important
PRT.24 DURING THE PAST 12 MONTHS, did you let any of the following CONVENTIONAL medical professionals know about your use of (modality)? Please say yes or no to each.
D.O. or Doctor of Osteopathy
M.D. or Medical Doctor including specialists
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist including specialists
Psychologist/Social Worker
Pharmacist
Traditional Healers
[NEW}
TRD.1 Have you ever seen any of the following practitioners? Please say yes or no to each.
(note: add pronunication guide from Dr. Zuniga)
(1) Native American Healer/Medicine Man
(2) Shaman (Shay-man)
(3) Curandero (coo-dan-der-oh)
(4) Espiritstas (Es-pee-dee-tee-stahs)
(5) Hierbero (yehr-bay-roh), Yerbera (yehr-bay-rah), or Hierbistas (yehr-bee-stahs)
(6) Sobadora (So-bah-door-a) or Sobador (So-bah-door)
(7) Hueseros (Weh-sehr-ohs)
(8) Santeros (Sahn-the-rohs)
(9) Machi (Mah-chee)
(10) Parteras (Pahr-the-dahs)
(11) Parcheros (Pahr-cheh-dohs)
[If no to all, goto next modality]
Cycle through TRD.2 for each yes in TRD.1
TRD.2 DURING THE PAST 12 MONTHS, did you see {fill: types of traditional healer}?
(1) Yes (next question)
(2) No to all (GO TO NEXT MODALITY)
[IF MORE THAN ONE YES in TRD.2, ASK TRD.2a; ELSE GO TO PRT.3]
TRD.2a During the past 12 months, which practitioner {fill from TRD.2} did you see the most?
_____________________ [TECHNIQUE]
*************Cycle through PRT.3 – PRT.24 for traditional practitioner**************
Movement Therapies
MOV.1 Have you ever seen a practitioner or teacher for any of the following? Please say yes or no to each.
(1) Feldenkreis yes no
(2) Alexander Technique yes no
(3) Pilates yes no
(4) Trager Psychophysical Intergration yes no
[If no to all, go to next modality]
Cycle through MOV.2 for each response in MOV.1
MOV.2 DURING THE PAST 12 MONTHS, did you see a practitioner or teacher for {fill: type of movement therapy}?
(1) Yes (next question)
(2) No to all (GO TO NEXT MODALITY)
[IF MORE THAN ONE YES in MOV.2, ASK MOV.2a; ELSE GO TO PRT.3]
MOV.2a During the past 12 months, which practitioner or teacher {fill from MOV.2} did you see the most?
_____________________ [TECHNIQUE]
********Cycle through PRT.3 – PRT.24 for practitioner for movement therapy*********
HERBS and Other Non-vitamin/non-mineral Dietary Supplements
Now I am going to ask you about some additional health practices. The first practice I’ll ask about is herbal supplements and other non-vitamin supplements. People take herbs and other non-vitamin supplements for a variety of reasons. By herbal and other non-vitamin supplements, we mean pills, capsules or tablets that have been labeled as a dietary supplement. This does NOT include vitamin or mineral supplements or drinking herbal or green tea.
HRB.1 Have you EVER taken any herbs and other non-vitamin supplements for yourself?
(1) Yes (2) No (Goto next modality)
HRB.2 DURING THE PAST 12 MONTHS have you taken any herbs and other non-vitamin supplements yourself?
(1) Yes (2) No (goto next modality)
HRB.5 DURING THE PAST 30 DAYS did you take any herbs and other non-vitamin supplements?
yes
no
NOTE FOR INTERVIEWER: A list of approximately 150 herbs provided to create alphabetic look-up table is attached. See INTERVIEWER CARD 1.
HRB.5a Please tell me which herbs and other non-vitamin supplements you took {in the past 30 days/in the past 12 months}. If you took more than one in a single supplement, say “combination pill.”
[MARK ALL THAT APPLY FROM LOOK-UP TABLE]
_______________________
_______________________
_______________________
_______________________
[IF COMBO HERB PILL SELECTED, ASK 5b, OTHERWISE GO TO HRB.6]
HRB.5b How many different “combination pills” did you take?
__________ [NUMBER]
HRB.5c What herbs or other non-vitamin supplements are included in [combination herb pill #1?, …#2?]
_______________________
_______________________
_______________________
_______________________
[IF MORE THAN 2 HERBS LISTED IN HRB.5a ASK HRB. 6, OTHERWISE GOTO HRB.7]
HRB.6 Which 2 of these herbs and other non-vitamin supplements did you take the most {in the past 30 days/in the past 12 months}?
[computer to display all herbs mentioned in 5a)
________________________
________________________
HRB.7 About how often do you buy herbs and other non-vitamin supplements?
______ times per day/week/month/year
FR: Read if necessary: this does not include vitamins or minerals.
HRB.8 About how much did you spend the last time you bought herbs and other non-vitamin supplements?
$ __________________
$0-$499 *Enter 500 for $500 or more
FR: Read if necessary: this does not include vitamins or minerals.
HRB.9 Have you EVER seen a practitioner for herbs and other non-vitamin supplements?
(1) Yes (HRB.10)
(2) No (PRT.3)
HRB.10 DURING THE PAST 12 MONTHS, did you see a practitioner for herbs and other non-vitamin supplements?
(1) Yes
(2) No
[NEW]
PRT.3 Do you currently use {herb #1/herb #2} more, less, or about the same as you did one year ago?
1) More
2) Less
3) About the same
[NEW]
PRT.4 Compared to the past 12 months, do you plan to use {herb #1/herb #2} more, less, or about the same during the next 12 months?
1) More
2) Less
3) About the same
PRT.5 (For respondents who said “no” to HRB.10 {seeing a practitioner} goto PRT.13)
During the past 12 months, were any of the costs of seeing a practitioner for herbs and other non-vitamin supplements covered by health insurance?
1) Yes (goto PRT.7)
2) No (goto PRT.11)
3) There was no cost for[modality](goto PRT.6)
[NEW]
PRT.6 During the past 12 months, how many times did you see a practitioner for herbs and other non-vitamin supplements with no costs?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.7 During the past 12 months, did your health insurance limit the number of visits to a practitioner or the dollar amount covered for herbs and other non-vitamin supplements?
1) Yes (goto PRT.7a)
2) No (goto PRT.9)
[NEW]
PRT.7a Which of these did your health insurance limit: the number of visits, the dollar amount, or both?
1) number of visits (PRT.8)
2) dollar amount (PRT.8a)
3) both (PRT.8)
[NEW]
PRT.8 During the past 12 months, how many visits to a practitioner for herbs and other non-vitamin supplements were covered by health insurance?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 marked in PRT.7a, else goto PRT.9)
PRT.8a During the past 12 months, what dollar amount did your health insurance cover for herbs and other non-vitamin supplements?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW]
PRT.9 How much was your co-payment per visit to a practitioner for herbs and other non-vitamin supplements {fill for yes to PRT.7: for visits covered by insurance}?
$ __________________ (if #1 to PRT.7 goto PRT.10 else goto PRT.11)
[NEW]
PRT.10 During the past 12 months, did you see a practitioner for herbs and other non-vitamin supplements more than was covered by health insurance?
1) Yes
2) No
[NEW]
PRT.11 During the past 12 months, how many times did you see a practitioner for herbs and other non-vitamin supplements {if yes to PRT.10 fill: that was not covered by health insurance}?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask #2 or #3 checked in PRT.7a, otherwise goto PRT.12)
PRT.11a During the past 12 months, did you spend more for herbs and other non-vitamin supplements than was covered by health insurance?
1) Yes (PRT.11b)
2) No (PRT.12)
[NEW]
PRT.11b During the past 12 months, how much more did you spend for herbs and other non-vitamin supplements than was covered by your health insurance?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW] (If no to PRT.7 skip this and goto PRT.13)
PRT.12 On average, how much did you pay out-of-pocket for each visit to a practitioner for herbs and other non-vitamin supplements {if yes to PRT.10 fill: that was not covered by insurance}?
$ __________________
$0-$499 *Enter 500 for $500 or more
[NEW]
PRT.13 During the past 12 months, did you buy a self-help book or other materials such as a DVD, CD, or Video to learn about herbs and other non-vitamin supplements?
(1) Yes (goto PRT.14)
(2) No (goto PRT.15)
[NEW]
PRT.14 How much did you pay for these materials?
$ ________________________
[NEW]
PRT.15 During the past 12 months, did you use [herb #1, herb #2] for any of these reasons? Please say yes or no to each.
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
Medical treatments were not helping you
Medical treatments were too expensive
[modality] combined with medical treatments would help you
To stay healthy
You thought it would be interesting to try [modality]
To improve your energy
To Improve your immune function
To improve your physical performance
To improve your athletic or sports performance
To improve your sexual performance
To improve your concentration
To improve your memory
To improve your flexibility
To improve your muscle strength
Because [modality] was recommended by a medical doctor
Because [modality] was recommended by family, friends, or co-workers
Because the practitioner spends more time with you than medical doctors
Because prescription or over-the-counter drugs are too expensive
Because you can do [modality] on your own
Because you do not want to take prescription medication
Because [modality] is natural
Because [modality] focuses on the entire body and not just one part
Because the practitioner treats your entire body and not just one part
Because you wanted to try something different
Because using [modality] is how I was raised
[NEW]
PRT.17 Thinking about your use of [herb #1/herb #2], please tell me if any of these statements are true for you. Please say yes or no to each.
Using [modality] has given you a sense of control over your health?
Using [modality] has helped you to relax?
Using [modality] has helped you to reduce your stress level?
Using [modality] has motivated you to eat healthier?
4a. In what ways are you eating healthier? Say yes or no to each.
Eating more organic foods
Eating more fruits and vegetables
Eating more fish
Eating less saturated fats or trans fats
Eating less processed sugar or less foods make with corn syrup
Eating less red meat
Eating fewer calories
Using [modality] has motivated you to cut back or stop drinking alcohol?
(5)Using [modality] has motivated you to cut back or stop smoking cigarettes, cigars, or pipes?
(6) Using [modality] has motivated you to exercise more regularly?
(7)Using [modality] has improved your overall health and made you feel better?
(8)Using [modality] has given you more hope for the future?
(9)Using [modality] has increased your ability to focus?
(10)Using [modality] has made you feel better emotionally?
(11)Using [modality] has made it easier to cope with health problems?
(12)Using [modality] has improved your outlook on life?
(13)Using [modality] has improved your relationships with others?
(14)Using [modality] has improved your self-confidence?
[NEW]
PRT.18 Of the following reasons, which was the most important reason for using [herb #1/herb #2]? (display if more than one of (1,2,3) chosen in question PRT.16 above)
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
(ask if 1,2, or 3 chosen in question PRT.16)
[NEW]
PRT.19 For what health problems or conditions did you use [herb #1/ herb #2] [to keep from getting/to prevent another occurance/to treat or cure]?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.20; else go to PRT.21]
PRT.20 For which ONE of these health conditions did you use [herb #1/ herb #2] the most?
_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using modality.
PRT.21 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[2002 Q.]
PRT.22 How much do you think [herb #1/ herb #2] helped your [condition]? Would you say a great deal, some, only a little, or not at all?
A great deal
Some
Only a little
Not at all
[2002 Q.]
PRT.23 NEW During the past 12 months, how important was your use of [herb #1/ herb #2] in maintaining your health and well-being? Would you say very important, somewhat important, slightly important, or not at all important?
Very important
Somewhat important
Slightly important
Not at all important
PRT.24 DURING THE PAST 12 MONTHS, did you let any of the following CONVENTIONAL medical professionals know about your use of [herb #1/ herb #2]? Please say yes or no to each.
D.O. or Doctor of Osteopathy
M.D. or Medical Doctor including specialists
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist including specialists
Psychologist/Social Worker
Pharmacist
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 Have you EVER used homeopathic treatment for yourself?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY - DIETS)
HOM.2 DURING THE PAST 12 MONTHS, did you use homeopathic treatment for your self?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY - DIETS)
HOM.3 About how often do you buy homeopathic medicine?
_____ times a day/week/month/year
HOM.4 And about how much did you spend the last time you bought homeopathic medicine?
$ __________________
HOM.5 Have you EVER seen a practitioner for homeopathic treatment?
(1) Yes
(2) No (GO TO PRT.3)
HOM.6 DURING THE PAST 12 MONTHS, did you see a practitioner for homeopathic treatment?
(1) Yes
(2) No
[NEW]
PRT.3 Do you currently use homeopathic treatment more, less, or about the same as you did one year ago?
1) More
2) Less
3) About the same
[NEW]
PRT.4 Compared to the past 12 months, do you plan to use homeopathic treatment more, less, or about the same during the next 12 months?
1) More
2) Less
3) About the same
[NEW]
PRT.5 (Ask this for respondents who report having health insurance in core, else goto PRT.11)
(For respondents who said “no” to HOM.6 {seeing a practitioner} goto PRT.13)
During the past 12 months, were any of the costs of seeing a practitioner for homeopathic treatment covered by health insurance?
1) Yes (goto PRT.7)
2) No (goto PRT.11)
3) There was no cost for[modality](goto PRT.6)
[NEW]
PRT.6 During the past 12 months, how many times did you see a practitioner for homeopathic treatment with no costs?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.7 During the past 12 months, did your health insurance limit the number of visits to a practitioner or the dollar amount covered for homeopathic treatment?
1) Yes (goto PRT.7a)
2) No (goto PRT.9)
[NEW]
PRT.7a Which of these did your health insurance limit: the number of visits, the dollar amount, or both?
1) number of visits (PRT.8)
2) dollar amount (PRT.8a)
3) both (PRT.8)
[NEW]
PRT.8 During the past 12 months, how many visits to a practitioner for homeopathic treatment were covered by health insurance?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 marked in PRT.7a, else goto PRT.9)
PRT.8a During the past 12 months, what dollar amount did your health insurance cover for homeopathic treatment?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW]
PRT.9 How much was your co-payment per visit to a practitioner for homeopathic treatment {fill for yes to PRT.7: for visits covered by insurance}?
$ __________________ (if #1 to PRT.7 goto PRT.10 else goto PRT.11)
[NEW]
PRT.10 During the past 12 months, did you see a practitioner for homeopathic treatment more than was covered by health insurance?
1) Yes
2) No
[NEW]
PRT.11 During the past 12 months, how many times did you see a practitioner for homeopathic treatment {if yes to PRT.10 fill: that was not covered by health insurance}?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
NEW] (ask #2 or #3 checked in PRT.7a, otherwise goto PRT.12)
PRT.11a During the past 12 months, did you spend more for homeopathic treatment than was covered by health insurance?
1) Yes (PRT.11b)
2) No (PRT.12)
[NEW]
PRT.11b During the past 12 months, how much more did you spend for homeopathic treatment than was covered by your health insurance?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW] (If no to PRT.7 skip this and goto PRT.13)
PRT.12 On average, how much did you pay out-of-pocket for each visit to a practitioner for homeopathic treatment {if yes to PRT.10 fill: that was not covered by insurance}?
$ __________________
$0-$499 *Enter 500 for $500 or more
[NEW]
PRT.13 During the past 12 months, did you buy a self-help book or other materials such as a DVD, CD, or Video to learn about homeopathic treatment?
(1) Yes (goto PRT.14)
(2) No (goto PRT.15)
[NEW]
PRT.14 How much did you pay for these materials?
$ ________________________
[NEW]
PRT.15 During the past 12 months, did you use homeopathic treatment for any of these reasons? Please say yes or no to each.
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
Medical treatments were not helping you
Medical treatments were too expensive
[modality] combined with medical treatments would help you
To stay healthy
You thought it would be interesting to try [modality]
To improve your energy
To Improve your immune function
To improve your physical performance
To improve your athletic or sports performance
To improve your sexual performance
To improve your concentration
To improve your memory
To improve your flexibility
To improve your muscle strength
Because [modality] was recommended by a medical doctor
Because [modality] was recommended by family, friends, or co-workers
Because the practitioner spends more time with you than medical doctors
Because prescription or over-the-counter drugs are too expensive
Because you can do [modality] on your own
Because you do not want to take prescription medication
Because [modality] is natural
Because [modality] focuses on the entire body and not just one part
Because the practitioner treats your entire body and not just one part
Because you wanted to try something different
Because using [modality] is how I was raised
[NEW]
PRT.17 Thinking about your use of homeopathic treatment, please tell me if any of these statements are true for you. Please say yes or no to each.
Using [modality] has given you a sense of control over your health?
Using [modality] has helped you to relax?
Using [modality] has helped you to reduce your stress level?
Using [modality] has motivated you to eat healthier?
4a. In what ways are you eating healthier? Say yes or no to each.
Eating more organic foods
Eating more fruits and vegetables
Eating more fish
Eating less saturated fats or trans fats
Eating less processed sugar or less foods make with corn syrup
Eating less red meat
Eating fewer calories
Using [modality] has motivated you to cut back or stop drinking alcohol?
(6)Using [modality] has motivated you to cut back or stop smoking cigarettes, cigars, or pipes?
(7) Using [modality] has motivated you to exercise more regularly?
(8)Using [modality] has improved your overall health and made you feel better?
(9)Using [modality] has given you more hope for the future?
(10)Using [modality] has increased your ability to focus?
(11)Using [modality] has made you feel better emotionally?
(12)Using [modality] has made it easier to cope with health problems?
(13)Using [modality] has improved your outlook on life?
(14)Using [modality] has improved your relationships with others?
(15)Using [modality] has improved your self-confidence?
[NEW]
PRT.18 Of the following reasons, which was the most important reason for using homeopathic treatment? (display if more than one of (1,2,3) chosen in question PRT.16 above)
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
(ask if 1,2, or 3 chosen in question PRT.16)
[NEW]
PRT.19 For what health problems or conditions did you use homeopathic treatment [to keep from getting/to prevent another occurance/to treat or cure]?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.20; else go to PRT.21]
PRT.20 For which ONE of these health conditions did you use homeopathic treatment the most?
_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using modality.
PRT.21 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[2002 Q.]
PRT.22 How much do you think homeopathic treatment helped your [condition]? Would you say a great deal, some, only a little, or not at all?
A great deal
Some
Only a little
Not at all
[2002 Q.]
PRT.23 NEW During the past 12 months, how important was your use of homeopathic treatment in maintaining your health and well-being? Would you say very important, somewhat important, slightly important, or not at all important?
Very important
Somewhat important
Slightly important
Not at all important
PRT.24 DURING THE PAST 12 MONTHS, did you let any of the following CONVENTIONAL medical professionals know about your use of homeopathic treatment? Please say yes or no to each.
D.O. or Doctor of Osteopathy
M.D. or Medical Doctor including specialists
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist including specialists
Psychologist/Social Worker
Pharmacist
SPECIAL DIETS
DIT.1 Have you EVER used 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 you use [diets mentioned in DIT.1] for two weeks or more for health reasons? [MARK ALL THAT APPLY]
yes
no to all [GO TO NEXT MODALITY]
[IF ONLY ONE DIET USED, GO TO DIT.4; ELSE ASK DIT.3]
DIT.3 During the past 12 months, which diet did you use the most?
_____________________ [DIET]
DIT.4 Did you use {diet used the most} for weight control or weight loss?
(1) Yes
(2) No
[new] DIT.5 Have you EVER seen a practitioner for special diets?
(1) Yes
(2) No (goto PRT.3)
DIT.6 DURING THE PAST 12 MONTHS, did you see a practitioner for special diets?
(1) Yes
(2) No (goto PRT.3)
DIT.7 What type of practitioner did you see?
medical doctor
nurse
dietician/nutritionist
alternative provider such as Acupuncturist, Chiropractor, Massage Therapist, Naturopath, etc. (next question)
[NEW]
PRT.3 Do you currently use {diet used the most} more, less, or about the same as you did one year ago?
1) More
2) Less
3) About the same
[NEW]
PRT.4 Compared to the past 12 months, do you plan to use {diet used the most} more, less, or about the same during the next 12 months?
1) More
2) Less
3) About the same
[NEW]
PRT.5 (Ask this for respondents who report having health insurance in core, else goto PRT.11)
(For respondents who said “no” to DIT.6 {seeing a practitioner} goto PRT.13)
During the past 12 months, were any of the costs of seeing a practitioner for special diets covered by health insurance?
1) Yes (goto PRT.7)
2) No (goto PRT.11)
3) There was no cost for[modality](goto PRT.6)
[NEW]
PRT.6 During the past 12 months, how many times did you see a practitioner for special diets with no costs?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.7 During the past 12 months, did your health insurance limit the number of visits to a practitioner or the dollar amount covered for visits to a practitioner of special diets?
1) Yes (goto PRT.7a)
2) No (goto PRT.9)
[NEW]
PRT.7a Which of these did your health insurance limit: the number of visits, the dollar amount, or both?
1) number of visits (PRT.8)
2) dollar amount (PRT.8a)
3) both (PRT.8)
[NEW]
PRT.8 During the past 12 months, how many visits to a practitioner for special diets were covered by health insurance?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 marked in PRT.7a, goto PRT.9)
PRT.8a During the past 12 months, what dollar amount did your health insurance cover for visits to a practitioner for special diets?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW]
PRT.9 How much was your co-payment per visit to a practitioner for special diets {fill for yes to PRT.7: for visits covered by insurance}?
$ __________________ (if #1 to PRT.7 goto PRT.10 else goto PRT.11)
[NEW]
PRT.10 During the past 12 months, did you see a practitioner for special diets more than was covered by health insurance?
1) Yes
2) No
[NEW]
PRT.11 During the past 12 months, how many times did you see a practitioner for special diets {if yes to PRT.10 fill: that was not covered by health insurance}?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask #2 or #3 checked in PRT.7a, otherwise goto PRT.12)
PRT.11a During the past 12 months, did you spend more for visits to a practitioner for special diets than was covered by health insurance?
1) Yes (PRT.11b)
2) No (PRT.12)
[NEW]
PRT.11b During the past 12 months, how much more did you spend for visits to a practitioner of special diets than was covered by your health insurance?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW] (If no to PRT.7 skip this and goto PRT.13)
PRT.12 On average, how much did you pay out-of-pocket for each visit to a practitioner for special diets {if yes to PRT.10 fill: that was not covered by insurance}?
$ __________________
$0-$499 *Enter 500 for $500 or more
[NEW]
PRT.13 During the past 12 months, did you buy a self-help book or other materials such as a DVD, CD, or Video to learn about special diets?
(1) Yes (goto PRT.14)
(2) No (goto PRT.15)
[NEW]
PRT.14 How much did you pay for these materials?
$ ________________________
[NEW]
PRT.15 During the past 12 months, did you use {diet used the most} for any of these reasons? Please say yes or no to each.
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
Medical treatments were not helping you
Medical treatments were too expensive
[modality] combined with medical treatments would help you
To stay healthy
You thought it would be interesting to try [modality]
To improve your energy
To Improve your immune function
To improve your physical performance
To improve your athletic or sports performance
To improve your sexual performance
To improve your concentration
To improve your memory
To improve your flexibility
To improve your muscle strength
Because [modality] was recommended by a medical doctor
Because [modality] was recommended by family, friends, or co-workers
Because the practitioner spends more time with you than medical doctors
Because prescription or over-the-counter drugs are too expensive
Because you can do [modality] on your own
Because you do not want to take prescription medication
Because [modality] is natural
Because [modality] focuses on the entire body and not just one part
Because the practitioner treats your entire body and not just one part
Because you wanted to try something different
Because using [modality] is how I was raised
[NEW]
PRT.17 Thinking about your use of{diet used the most}, please tell me if any of these statements are true for you. Please say yes or no to each.
Using [modality] has given you a sense of control over your health?
Using [modality] has helped you to relax?
Using [modality] has helped you to reduce your stress level?
Using [modality] has motivated you to eat healthier?
4a. In what ways are you eating healthier? Say yes or no to each.
Eating more organic foods
Eating more fruits and vegetables
Eating more fish
Eating less saturated fats or trans fats
Eating less processed sugar or less foods make with corn syrup
Eating less red meat
Eating fewer calories
Using [modality] has motivated you to cut back or stop drinking alcohol?
(6)Using [modality] has motivated you to cut back or stop smoking cigarettes, cigars, or pipes?
(7) Using [modality] has motivated you to exercise more regularly?
(8)Using [modality] has improved your overall health and made you feel better?
(9)Using [modality] has given you more hope for the future?
(10)Using [modality] has increased your ability to focus?
(11)Using [modality] has made you feel better emotionally?
(12)Using [modality] has made it easier to cope with health problems?
(13)Using [modality] has improved your outlook on life?
(14)Using [modality] has improved your relationships with others?
(15)Using [modality] has improved your self-confidence?
[NEW]
PRT.18 Of the following reasons, which was the most important reason for using {diet used the most}? (display if more than one of (1,2,3) chosen in question PRT.16 above)
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
(ask if 1,2, or 3 chosen in question PRT.16)
[NEW]
PRT.19 For what health problems or conditions did you use {diet used the most} [to keep from getting/to prevent another occurance/to treat or cure]?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.20; else go to PRT.21]
PRT.20 For which ONE of these health conditions did you use {diet used the most} the most?
_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using modality.
PRT.21 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[2002 Q.]
PRT.22 How much do you think {diet used the most} helped your [condition]? Would you say a great deal, some, only a little, or not at all?
A great deal
Some
Only a little
Not at all
[2002 Q.]
PRT.23 NEW During the past 12 months, how important was your use of {diet used the most} in maintaining your health and well-being? Would you say very important, somewhat important, slightly important, or not at all important?
Very important
Somewhat important
Slightly important
Not at all important
PRT.24 DURING THE PAST 12 MONTHS, did you let any of the following CONVENTIONAL medical professionals know about your use of {diet used the most}? Please say yes or no to each.
D.O. or Doctor of Osteopathy
M.D. or Medical Doctor including specialists
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist including specialists
Psychologist/Social Worker
Pharmacist
YOGA/TAI CHI/QI GONG
YOG.1 Have you EVER practiced 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]
Cycle through for each yes answer in YOG.1
YOG.2 DURING THE PAST 12 MONTHS, did you practice [exercise mentioned in YOG.1] for yourself?
(1) Yes
(2) No to all [goto next modality]
[IF MORE THAN ONE EXERCISE MENTIONED in YOG.2, ASK YOG.3; OTHERWISE GO TO YOG.4]
YOG.3 During the past 12 months, which exercise {fill from YES responses to YOG.2} did you practice the most?
_____________________ [EXERCISE]
YOG.4 DURING THE PAST 12 MONTHS, did you take a {fill type of exercise} class or in some way receive formal training? Attending only one session does not count.
(1) Yes
(2) No
[NEW]
PRT.3 Do you currently use {fill type of exercise} more, less, or about the same as you did one year ago?
1) More
2) Less
3) About the same
[NEW]
PRT.4 Compared to the past 12 months, do you plan to use {fill type of exercise} more, less, or about the same during the next 12 months?
1) More
2) Less
3) About the same
[NEW]
PRT.5 (Ask this for respondents who report having health insurance in core, else goto PRT.11)
(For respondents who said “no” to YOG.4 {taking a class} goto PRT.13)
During the past 12 months, were any of the costs of taking a {fill type of exercise} class covered by health insurance?
1) Yes (goto PRT.7)
2) No (goto PRT.11)
3) There was no cost for[modality](goto PRT.6)
[NEW]
PRT.6 During the past 12 months, how many times did you take a {fill type of exercise} class with no costs?
____________________ (number of classes)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.7 During the past 12 months, did your health insurance limit the number of classes or the dollar amount covered for {fill type of exercise}?
1) Yes (goto PRT.7a)
2) No (goto PRT.9)
[NEW]
PRT.7a Which of these did your health insurance limit: the number of visits, the dollar amount, or both?
1) number of visits (PRT.8)
2) dollar amount (PRT.8a)
3) both (PRT.8)
[NEW]
PRT.8 During the past 12 months, how many classes for {fill type of exercise} were covered by health insurance?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 marked in PRT.7a, else goto PRT.9)
PRT.8a During the past 12 months, what dollar amount did your health insurance cover for{fill type of exercise} classes?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW]
PRT.9 How much was your co-payment per class for {fill type of exercise} {fill for yes to PRT.7: for visits covered by insurance}?
$ __________________ (if #1 to PRT.7 goto PRT.10 else goto PRT.11)
[NEW]
PRT.10 During the past 12 months, did you take more {fill type of exercise} classes than were covered by health insurance?
1) Yes
2) No
[NEW]
PRT.11 During the past 12 months, how many {fill type of exercise} classes did you take {if yes to PRT.10 fill: that was not covered by health insurance}?
____________________ (number of classes)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask #2 or #3 checked in PRT.7a, otherwise goto PRT.12)
PRT.11a During the past 12 months, did you spend more for{fill type of exercise} classes than was covered by health insurance?
1) Yes (PRT.11b)
2) No (PRT.12)
[NEW]
PRT.11b During the past 12 months, how much more did you spend for {fill type of exercise} classes than was covered by your health insurance?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW] (If no to PRT.7 skip this and goto PRT.13)
PRT.12 On average, how much did you pay out-of-pocket for each {fill type of exercise} class {if yes to PRT.10 fill: that was not covered by insurance}?
$ __________________
$0-$499 *Enter 500 for $500 or more
[NEW]
PRT.13 During the past 12 months, did you buy a self-help book or other materials such as a DVD, CD, or Video to learn about {fill type of exercise}?
(1) Yes (goto PRT.14)
(2) No (goto PRT.15)
[NEW]
PRT.14 How much did you pay for these materials?
$ ________________________
[NEW]
PRT.15 During the past 12 months, did you use {fill type of exercise} for any of these reasons? Please say yes or no to each.
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
Medical treatments were not helping you
Medical treatments were too expensive
[modality] combined with medical treatments would help you
To stay healthy
You thought it would be interesting to try [modality]
To improve your energy
To Improve your immune function
To improve your physical performance
To improve your athletic or sports performance
To improve your sexual performance
To improve your concentration
To improve your memory
To improve your flexibility
To improve your muscle strength
Because [modality] was recommended by a medical doctor
Because [modality] was recommended by family, friends, or co-workers
Because the practitioner spends more time with you than medical doctors
Because prescription or over-the-counter drugs are too expensive
Because you can do [modality] on your own
Because you do not want to take prescription medication
Because [modality] is natural
Because [modality] focuses on the entire body and not just one part
Because the practitioner treats your entire body and not just one part
Because you wanted to try something different
Because using [modality] is how I was raised
[NEW]
PRT.17 Thinking about your use of {fill type of exercise}, please tell me if any of these statements are true for you. Please say yes or no to each.
Using [modality] has given you a sense of control over your health?
Using [modality] has helped you to relax?
Using [modality] has helped you to reduce your stress level?
Using [modality] has motivated you to eat healthier?
4a. In what ways are you eating healthier? Say yes or no to each.
Eating more organic foods
Eating more fruits and vegetables
Eating more fish
Eating less saturated fats or trans fats
Eating less processed sugar or less foods make with corn syrup
Eating less red meat
Eating fewer calories
Using [modality] has motivated you to cut back or stop drinking alcohol?
(6)Using [modality] has motivated you to cut back or stop smoking cigarettes, cigars, or pipes?
(7) Using [modality] has motivated you to exercise more regularly?
(8)Using [modality] has improved your overall health and made you feel better?
(9)Using [modality] has given you more hope for the future?
(10)Using [modality] has increased your ability to focus?
(11)Using [modality] has made you feel better emotionally?
(12)Using [modality] has made it easier to cope with health problems?
(13)Using [modality] has improved your outlook on life?
(14)Using [modality] has improved your relationships with others?
(15)Using [modality] has improved your self-confidence?
[NEW]
PRT.18 Of the following reasons, which was the most important reason for using {fill type of exercise}? (display if more than one of (1,2,3) chosen in question PRT.16 above)
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
(ask if 1,2, or 3 chosen in question PRT.16)
[NEW]
PRT.19 For what health problems or conditions did you use {fill type of exercise} [to keep from getting/to prevent another occurance/to treat or cure]?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.20; else go to PRT.21]
PRT.20 For which ONE of these health conditions did you use {fill type of exercise} the most?
_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using modality.
PRT.21 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[2002 Q.]
PRT.22 How much do you think {fill type of exercise} helped your [condition]? Would you say a great deal, some, only a little, or not at all?
A great deal
Some
Only a little
Not at all
[2002 Q.]
PRT.23 NEW During the past 12 months, how important was your use of {fill type of exercise} in maintaining your health and well-being? Would you say very important, somewhat important, slightly important, or not at all important?
Very important
Somewhat important
Slightly important
Not at all important
PRT.24 DURING THE PAST 12 MONTHS, did you let any of the following CONVENTIONAL medical professionals know about your use of {fill type of exercise}? Please say yes or no to each.
Medical Doctor (including specialists)
Doctor of Osteopathy (D.O.)
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist (including specialists)
Psychologist/Social Worker
Pharmacist
RELAXATION and STRESS MANAGEMENT TECHNIQUES
REL.1 Have you EVER used any of the following relaxation or stress management techniques for your self? 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
[IF NO TO ALL, GO TO prayer]
Cycle through for every yes in REL.1
REL.2 DURING THE PAST 12 MONTHS, did you use [methods mentioned in REL.1] for yourself?
(1) Yes
(2) No to all (GO TO PRAYER)
[IF MORE THAN ONE YES in REL.2, ASK REL.3; ELSE GO TO REL.4]
REL.3 During the past 12 months, which relaxation techniques {fill techniques from REL. 2} did you use the most?
_____________________ [TECHNIQUE]
REL.4 DURING THE PAST 12 MONTHS, did you see a practitioner or take a class for {relaxation technique used the most}?
(1) Yes
(2) No
[NEW]
PRT.3 Do you currently use {relaxation technique used the most} more, less, or about the same as you did one year ago?
1) More
2) Less
3) About the same
[NEW]
PRT.4 Compared to the past 12 months, do you plan to use {relaxation technique used the most} more, less, or about the same during the next 12 months?
1) More
2) Less
3) About the same
[NEW]
PRT.5 (Ask this for respondents who report having health insurance in core, else goto PRT.11)
(For respondents who said “no” to REL.4 {seeing a practitioner} goto PRT.13)
During the past 12 months, were any of the costs of seeing a practitioner or taking a class for{relaxation technique used the most} covered by health insurance?
1) Yes (goto PRT.7)
2) No (goto PRT.11)
3) There was no cost for[modality](goto PRT.6)
[NEW]
PRT.6 During the past 12 months, how many times did you see a practitioner or take a class for {relaxation technique used the most} with no costs?
____________________ (number of visits/classes)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.7 During the past 12 months, did your health insurance limit the number of visits to a practitioner, the number of classes, or the dollar amount covered for {relaxation technique used the most}?
1) Yes (goto PRT.7a)
2) No (goto PRT.9)
[NEW]
PRT.7a Which of these did your health insurance limit: the number of visits, the dollar amount, or both?
number of visits to practioner (PRT.8)
number of classes (PRT.8a)
3) dollar amount (PRT.8b)
4) both (PRT.8)
[NEW]
PRT.8 During the past 12 months, how many visits to a practitioner for {relaxation technique used the most} were covered by health insurance?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.8a During the past 12 months, how many classes for {relaxation technique used the most} were covered by health insurance?
____________________ (number of classes)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 marked in PRT.7a, else goto PRT.9)
PRT.8b During the past 12 months, what dollar amount did your health insurance cover for{relaxation technique used the most}?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW]
PRT.9 How much was your co-payment per visit to a practitioner for {relaxation technique used the most} {fill for yes to PRT.7: for visits covered by insurance}?
$ __________________ (if #1 to PRT.7 goto PRT.10 else goto PRT.11)
[NEW]
PRT.9a How much was your co-payment per class for {relaxation technique used the most} {fill for yes to PRT.7: for visits covered by insurance}?
$ __________________ (if #1 to PRT.7 goto PRT.10 else goto PRT.11)
[NEW]
PRT.10 During the past 12 months, did you see a practitioner or take a class for {relaxation technique used the most} more than was covered by health insurance?
1) Yes
2) No
[NEW]
PRT.11 During the past 12 months, how many times did you see a practitioner for {relaxation technique used the most} {if yes to PRT.10 fill: that was not covered by health insurance}?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.11a During the past 12 months, how many times did you take a class for {relaxation technique used the most}{if yes to PRT.10 fill: that was not covered by health insurance}?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask #2 or #3 checked in PRT.7a)
PRT.11b During the past 12 months, did you spend more for {relaxation technique used the most} than was covered by health insurance?
1) Yes (PRT.11c)
2) No (PRT.12)
[NEW]
PRT.11c During the past 12 months, how much more did you spend for {relaxation technique used the most} than was covered by your health insurance?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW] (If no to PRT.7 skip this and goto PRT.13)
PRT.12 On average, how much did you pay out-of-pocket for each visit to a practitioner or class for{relaxation technique used the most}{if yes to PRT.10 fill: that was not covered by insurance}?
$ __________________
$0-$499 *Enter 500 for $500 or more
[NEW]
PRT.13 During the past 12 months, did you buy a self-help book or other materials such as a DVD, CD, or Video to learn about {relaxation technique used the most}?
(1) Yes (goto PRT.14)
(2) No (goto PRT.15)
[NEW]
PRT.14 How much did you pay for these materials?
$ ________________________
[NEW]
PRT.15 During the past 12 months, did you use {relaxation technique used the most} for any of these reasons? Please say yes or no to each.
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
Medical treatments were not helping you
Medical treatments were too expensive
[modality] combined with medical treatments would help you
To stay healthy
You thought it would be interesting to try [modality]
To improve your energy
To Improve your immune function
To improve your physical performance
To improve your athletic or sports performance
To improve your sexual performance
To improve your concentration
To improve your memory
To improve your flexibility
To improve your muscle strength
18. Because [modality] was recommended by a medical doctor
Because [modality] was recommended by family, friends, or co-workers
Because the practitioner spends more time with you than medical doctors
Because prescription or over-the-counter drugs are too expensive
Because you can do [modality] on your own
Because you do not want to take prescription medication
Because [modality] is natural
Because [modality] focuses on the entire body and not just one part
Because the practitioner treats your entire body and not just one part
Because you wanted to try something different
Because using [modality] is how I was raised
[NEW]
PRT.17 Thinking about your use of {relaxation technique used the most}, please tell me if any of these statements are true for you. Please say yes or no to each.
Using [modality] has given you a sense of control over your health?
Using [modality] has helped you to relax?
Using [modality] has helped you to reduce your stress level?
Using [modality] has motivated you to eat healthier?
4a. In what ways are you eating healthier? Say yes or no to each.
Eating more organic foods
Eating more fruits and vegetables
Eating more fish
Eating less saturated fats or trans fats
Eating less processed sugar or less foods make with corn syrup
Eating less red meat
Eating fewer calories
(5) Using [modality] has motivated you to cut back or stop drinking alcohol?
(6)Using [modality] has motivated you to cut back or stop smoking cigarettes, cigars, or pipes?
(7) Using [modality] has motivated you to exercise more regularly?
(8)Using [modality] has improved your overall health and made you feel better?
(9)Using [modality] has given you more hope for the future?
(10)Using [modality] has increased your ability to focus?
(11)Using [modality] has made you feel better emotionally?
(12)Using [modality] has made it easier to cope with health problems?
(13)Using [modality] has improved your outlook on life?
(14)Using [modality] has improved your relationships with others?
(15)Using [modality] has improved your self-confidence?
[NEW]
PRT.18 Of the following reasons, which was the most important reason for using {relaxation technique used the most}? (display if more than one of (1,2,3) chosen in question PRT.16 above)
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
(ask if 1,2, or 3 chosen in question PRT.16)
[NEW]
PRT.19 For what health problems or conditions did you use {relaxation technique used the most} [to keep from getting/to prevent another occurance/to treat or cure]?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.20; else go to PRT.21]
PRT.20 For which ONE of these health conditions did you use {relaxation technique used the most} the most?
_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using modality.
PRT.21 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[2002 Q.]
PRT.22 How much do you think {relaxation technique used the most} helped your [condition]? Would you say a great deal, some, only a little, or not at all?
A great deal
Some
Only a little
Not at all
[2002 Q.]
PRT.23 NEW During the past 12 months, how important was your use of {relaxation technique used the most} in maintaining your health and well-being? Would you say very important, somewhat important, slightly important, or not at all important?
Very important
Somewhat important
Slightly important
Not at all important
PRT.24 DURING THE PAST 12 MONTHS, did you let any of the following CONVENTIONAL medical professionals know about your use of {relaxation technique used the most}? Please say yes or no to each.
D.O. or Doctor of Osteopathy
M.D. or Medical Doctor including specialists
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist including specialists
Psychologist/Social Worker
Pharmacist
PRAYER FOR YOUR OWN HEALTH
Now I am going to ask you about your use of prayer for your own health.
PRY.1 Have you EVER prayed specifically for the purpose of your OWN health?
(1) Yes (next question)
(2) No (GO TO PRY.3)
PRY.2 DURING THE PAST 12 MONTHS, did you pray specifically for the purpose of your OWN health?
(1) Yes
(2) No
PRY.3 Have you EVER asked or had OTHERS pray for your OWN health?
(1) Yes
(2) No [GO TO PERCEPTIONS]
PRY.4 DURING THE PAST 12 MONTHS, did you ask or have others pray for your OWN health?
(1) Yes
(2) No
Complementary and Alternative Medicine Supplement
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 with his/her family or on his/her own.
Modalities that Require Practitioner
PRT.1 Has {child’s name} EVER seen a provider or practitioner for any of the following therapies for themself? Please say yes or no to each.
(1) Acupuncture yes no
(2) Ayurveda yes no
(3) Biofeedback yes no
(4) Chelation (key-LAY-shun) Therapy yes no
(5) Chiropractic (kye-row-PRAK-tik) or Osteopathic Manipulation yes no
(6) Energy Healing Therapy yes no
(7) Hypnosis yes no
(8) Massage yes no
(9) Naturopathy (nay-chur-AH-puh-thee) yes no
[IF NO TO ALL, GO TO Traditional healers]
PRT.2 DURING THE PAST 12 MONTHS, did {child’s name} see a practitioner for (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY )
[NEW]
PRT.3 Does {child’s name} currently use [modality] more, less, or about the same as {he/she} did one year ago?
1) More
2) Less
3) About the same
[NEW]
PRT.4 Compared to the past 12 months, does {child’s name} plan to use [modality] more, less, or about the same during the next 12 months?
1) More
2) Less
3) About the same
[NEW]
PRT.5 (Ask this for respondents who report having health insurance in core, else goto PRT.11)
During the past 12 months, were any of the costs of using (modality) covered by health insurance?
1) Yes (goto PRT.7)
2) No (goto PRT.11)
3) There was no cost for[modality](goto PRT.6)
[NEW]
PRT.6 During the past 12 months, how many times did {child’s name} see a practitioner for (modality) with no costs?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.7 During the past 12 months, did {child’s name’s} health insurance limit the number of visits to a practitioner or the dollar amount covered for (modality)?
1) Yes (goto PRT.7a)
2) No (goto PRT.9)
[NEW]
PRT.7a Which of these did {child’s name} health insurance limit: the number of visits, the dollar amount, or both?
1) number of visits (PRT.8)
2) dollar amount (PRT.8a)
3) both (PRT.8)
[NEW]
PRT.8 During the past 12 months, how many visits for {child’s name} to see a practitioner for (modality) were covered by health insurance?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 marked in PRT.7a, else goto PRT.9)
PRT.8a During the past 12 months, what dollar amount did {child’s name} health insurance cover for (modality)?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW]
PRT.9 How much was co-payment per visit for {child’s name} to see a practitioner for (modality) {fill for yes to PRT.7: for visits covered by insurance}?
$ __________________ (if #1 to PRT.7 goto PRT.10 else goto PRT.11)
[NEW]
PRT.10 During the past 12 months, did {child’s name} see a practitioner for (modality) more than was covered by health insurance?
1) Yes
2) No
[NEW]
PRT.11 During the past 12 months, how many times did {child’s name} see a practitioner for (modality) {if yes to PRT.10 fill: that was not covered by health insurance}?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 checked in PRT.7a, otherwise goto PRT.12)
PRT.11a During the past 12 months, were the costs for {child’s name} to use (modality) more than was covered by health insurance?
1) Yes (PRT.11b)
2) No (PRT.12)
[NEW]
PRT.11b During the past 12 months, how much more were the costs for {child’s name} to see a practitioner for (modality) than was covered by health insurance?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW] (If no to PRT.7 skip this and goto PRT.13)
PRT.12 On average, what was the cost out-of-pocket for each of {child’s name} visits to a practitioner for [modality] {if yes to PRT.10 fill: that was not covered by insurance}?
$ __________________
$0-$499 *Enter 500 for $500 or more
[NEW]
PRT.13 During the past 12 months, did you or {child’s name} buy a self-help book or other materials such as a DVD, CD, or Video to learn about (modality)?
(1) Yes (goto PRT.14)
(2) No (goto PRT.15)
[NEW]
PRT.14 How much did you or {child’s name} pay for these materials?
$ ________________________
[NEW]
PRT.15 During the past 12 months, did {child’s name} use [modality] for any of these reasons? Please say yes or no to each.
To keep {child’s name} from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem {child’s name} has now
Medical treatments were not helping {child’s name}
Medical treatments were too expensive
[modality] combined with medical treatments would help {child’s name}
So {child’s name} would stay healthy
You or {child’s name} thought it would be interesting to try [modality]
To improve {child’s name} energy
To Improve {child’s name} immune function
To improve {child’s name} physical performance
To improve {child’s name} athletic or sports performance
To improve {child’s name} concentration
To improve {child’s name} memory
To improve {child’s name} flexibility
To improve {child’s name} muscle strength
Because [modality] was recommended by a medical doctor
Because [modality] was recommended by family, friends, or co-workers
Because the practitioner spends more time with {child’s name} than medical doctors
Because prescription or over-the-counter drugs are too expensive
Because you or {child’s name} can do [modality] on your own
Because you do not want {child’s name} to take prescription medication
Because [modality] is natural
Because [modality] focuses on the entire body and not just one part
Because the practitioner treats the entire body and not just one part
Because you or {child’s name} wanted to try something different
Because using [modality] is how you or {child’s name} were raised
[NEW]
PRT.17 Thinking about your use of [modality], please tell me if any of these statements are true for you. Please say yes or no to each.
Using [modality] has given you or {child’s name} a sense of control over your/his/her health?
Using [modality] has helped {child’s name} to relax?
Using [modality] has helped {child’s name} to reduce his/her stress level?
Using [modality] has motivated {child’s name} to eat healthier?
4a. In what ways are {child’s name} eating healthier? Say yes or no to each.
Eating more organic foods
Eating more fruits and vegetables
Eating more fish
Eating less saturated fats or trans fats
Eating less processed sugar or less foods make with corn syrup
Eating less red meat
Eating fewer calories
[for parent of child age 14+] Using [modality] has motivated {child’s name} to cut back or stop drinking alcohol?
(6) [for parent of child age 14+] Using [modality] has motivated {child’s name} to cut back or stop smoking cigarettes, cigars, or pipes?
(7) Using [modality] has motivated {child’s name} to exercise more regularly?
(8)Using [modality] has improved {child’s name} overall health and made him/her feel better?
(9)Using [modality] has given {child’s name} more hope for the future?
(10)Using [modality] has increased {child’s name} ability to focus?
(11)Using [modality] has made {child’s name} feel better emotionally?
(12)Using [modality] has made it easier for {child’s name} to cope with health problems?
(13)Using [modality] has improved {child’s name} outlook on life?
(14)Using [modality] has improved {child’s name} relationships with others?
(15)Using [modality] has improved {child’s name} self-confidence?
[NEW]
PRT.18 Of the following reasons, which was the most important reason for {child’s name} use of [modality]? (display if more than one of (1,2,3) chosen in question PRT.16 above)
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem {child’s name} has now
(ask if 1,2, or 3 chosen in question PRT.16)
[NEW]
PRT.19 For what health problems or conditions did {child’s name} use [modality] [to keep from getting/to prevent another occurance/to treat or cure]?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.20; else go to PRT.21]
PRT.20 For which ONE of these health conditions did {child’s name} use (modality) the most?
_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using modality.
PRT.21 Did {child’s name} receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[2002 Q.]
PRT.22 How much do you think [modality] helped {child’s name} [condition]? Would you say a great deal, some, only a little, or not at all?
A great deal
Some
Only a little
Not at all
[2002 Q.]
PRT.23 NEW During the past 12 months, how important was {child’s name} use of [modality] in maintaining his/her health and well-being? Would you say very important, somewhat important, slightly important, or not at all important?
Very important
Somewhat important
Slightly important
Not at all important
PRT.24 DURING THE PAST 12 MONTHS, did you or {child’s name} let any of the following CONVENTIONAL medical professionals know about {child’s name} use of (modality)? Please say yes or no to each.
D.O. or Doctor of Osteopathy
M.D. or Medical Doctor including specialists
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist including specialists
Psychologist/Social Worker
Pharmacist
Traditional Healers
[NEW}
TRD.1 Has {child’s name} ever seen any of the following practitioners? Please say yes or no to each.
(note: add pronunication guide from Dr. Zuniga)
(1) Native American Healer/Medicine Man
(2) Shaman (Shay-man)
(3) Curandero (coo-dan-der-oh)
(4) Espiritstas (Es-pee-dee-tee-stahs)
(5) Hierbero (yehr-bay-roh), Yerbera (yehr-bay-rah), or Hierbistas (yehr-bee-stahs)
(6) Sobadora (So-bah-door-a) or Sobador (So-bah-door)
(7) Hueseros (Weh-sehr-ohs)
(8) Santeros (Sahn-the-rohs)
(9) Machi (Mah-chee)
(10) Parteras (Pahr-the-dahs)
(11) Parcheros (Pahr-cheh-dohs)
[If no to all, goto next modality]
Cycle through TRD.2 for each yes in TRD.1
TRD.2 DURING THE PAST 12 MONTHS, did {child’s name} see {fill: types of traditional healer}?
(1) Yes (next question)
(2) No to all (GO TO NEXT MODALITY)
[IF MORE THAN ONE YES in TRD.2, ASK TRD.2a; ELSE GO TO PRT.3]
TRD.2a During the past 12 months, which practitioner {fill from TRD.2} did {child’s name} see the most?
_____________________ [TECHNIQUE]
*************Cycle through PRT.3 – PRT.24 for traditional practitioner**************
Movement Therapies
MOV.1 Has {child’s name} ever seen a practitioner or teacher for any of the following? Please say yes or no to each.
(1) Feldenkreis yes no
(2) Alexander Technique yes no
(3) Pilates yes no
(4) Trager Psychophysical Intergration yes no
[If no to all, goto next modality]
Cycle through MOV.2 for each response in MOV.1
MOV.2 DURING THE PAST 12 MONTHS, did {child’s name} see a practitioner or teacher for {fill: type of movement therapy}?
(1) Yes (next question)
(2) No to all (GO TO NEXT MODALITY)
[IF MORE THAN ONE YES in MOV.2, ASK MOV.2a; ELSE GO TO PRT.3]
MOV.2a During the past 12 months, which practitioner or teacher {fill from MOV.2} did {child’s name} see the most?
_____________________ [TECHNIQUE]
********Cycle through PRT.3 – PRT.24 for practitioner for movement therapy*********
HERBS and Other Non-vitamin/non-mineral Dietary Supplements
Now I am going to ask you about some additional health practices. The first practice I’ll ask about is herbal supplements and other non-vitamin supplements. People take herbs and other non-vitamin supplements for a variety of reasons. By herbal and other non-vitamin supplements, we mean pills, capsules or tablets that have been labeled as a dietary supplement. This does NOT include vitamin or mineral supplements or drinking herbal or green tea.
HRB.1 Has {child’s name} EVER taken any herbs and other non-vitamin supplements?
(1) Yes (2) No (Goto next modality)
HRB.2 DURING THE PAST 12 MONTHS did {child’s name} taken any herbs and other non-vitamin supplements?
(1) Yes (2) No (goto next modality)
HRB.5 DURING THE PAST 30 DAYS did {child’s name} take any herbs and other non-vitamin supplements?
yes
no
(list of approximately 150 herbs provided to create alphabetic look-up table)
HRB.5a Please tell me which herbs and other non-vitamin supplements {child’s name} took {in the past 30 days/in the past 12 months}. If you took more than one in a single supplement, say “combination pill.”
_______________________
_______________________
_______________________
_______________________
[IF COMBO HERB PILL SELECTED, ASK 5b, OTHERWISE GO TO HRB.6]
HRB.5b How many different “combination pills” did {child’s name} take?
__________ [NUMBER]
HRB.5c What herbs or other non-vitamin supplements are included in [combination herb pill #1?, …#2?]
_______________________
_______________________
_______________________
_______________________
[IF MORE THAN 2 HERBS LISTED IN HRB.5a ASK HRB. 6, OTHERWISE GOTO HRB.7]
HRB.6 Which 2 of these herbs and other non-vitamin supplements did {child’s name} take the most {in the past 30 days/in the past 12 months}?
[computer to display all herbs mentioned in 5a)
________________________
________________________
HRB.7 About how often do you buy herbs and other non-vitamin supplements for {child’s name}?
______ times per day/week/month/year
FR: Read if necessary: this does not include vitamins or minerals.
HRB.8 About how much did you spend the last time you bought herbs and other non-vitamin supplements for {child’s name}?
$ __________________
$0-$499 *Enter 500 for $500 or more
FR: Read if necessary: this does not include vitamins or minerals.
HRB.9 Has {child’s name} EVER seen a practitioner for herbs and other non-vitamin supplements?
(1) Yes (HRB.10)
(2) No (PRT.3)
HRB.10 DURING THE PAST 12 MONTHS, did {child’s name} see a practitioner for herbs and other non-vitamin supplements?
(1) Yes
(2) No
[NEW]
PRT.3 Does {child’s name} currently use {herb #1/herb #2} more, less, or about the same as you did one year ago?
1) More
2) Less
3) About the same
[NEW]
PRT.4 Compared to the past 12 months, does {child’s name} plan to use {herb #1/herb #2} more, less, or about the same during the next 12 months?
1) More
2) Less
3) About the same
[NEW]
PRT.5 (Ask this for respondents who report having health insurance in core, else goto PRT.11)
(For respondents who said “no” to HRB.10 {seeing a practitioner} goto PRT.13)
During the past 12 months, were any of the costs of seeing a practitioner for herbs and other non-vitamin supplements covered by health insurance?
1) Yes (goto PRT.7)
2) No (goto PRT.11)
3) There was no cost for[modality](goto PRT.6)
[NEW]
PRT.6 During the past 12 months, how many times did {child’s name} see a practitioner for herbs and other non-vitamin supplements with no costs?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.7 During the past 12 months, did {child’s name’s} health insurance limit the number of visits to a practitioner or the dollar amount covered for herbs and other non-vitamin supplements?
1) Yes (goto PRT.7a)
2) No (goto PRT.9)
[NEW]
PRT.7a Which of these did {child’s name’s} health insurance limit: the number of visits, the dollar amount, or both?
1) number of visits (PRT.8)
2) dollar amount (PRT.8a)
3) both (PRT.8)
[NEW]
PRT.8 During the past 12 months, how many visits for {child’s name} to see a practitioner for herbs and other non-vitamin supplements were covered by health insurance?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 marked in PRT.7a, else goto PRT.9)
PRT.8a During the past 12 months, what dollar amount did {child’s name} health insurance cover for herbs and other non-vitamin supplements?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW]
PRT.9 How much was co-payment per visit for {child’s name} to see a practitioner for herbs and other non-vitamin supplements {fill for yes to PRT.7: for visits covered by insurance}?
$ __________________ (if #1 to PRT.7 goto PRT.10 else goto PRT.11)
[NEW]
PRT.10 During the past 12 months, did {child’s name} see a practitioner for herbs and other non-vitamin supplements more than was covered by health insurance?
1) Yes
2) No
[NEW]
PRT.11 During the past 12 months, how many times did {child’s name} see a practitioner for herbs and other non-vitamin supplements {if yes to PRT.10 fill: that was not covered by health insurance}?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 checked in PRT.7a, otherwise goto PRT.12)
PRT.11a During the past 12 months, were the costs for {child’s name} to see a practitioner for herbs and other non-vitamin supplements more than was covered by health insurance?
1) Yes (PRT.11b)
2) No (PRT.12)
[NEW]
PRT.11b During the past 12 months, how much more were the costs for {child’s name} to see a practitioner for herbs and other non-vitamin supplements than was covered by health insurance?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW] (If no to PRT.7 skip this and goto PRT.13)
PRT.12 On average, what was the cost out-of-pocket for each of {child’s name} visits to a practitioner for herbs and other non-vitamin supplements {if yes to PRT.10 fill: that was not covered by insurance}?
$ __________________
$0-$499 *Enter 500 for $500 or more
[NEW]
PRT.13 During the past 12 months, did you or {child’s name} buy a self-help book or other materials such as a DVD, CD, or Video to learn about herbs and other non-vitamin supplements?
(1) Yes (goto PRT.14)
(2) No (goto PRT.15)
[NEW]
PRT.14 How much did you or {child’s name} pay for these materials?
$ ________________________
[NEW]
PRT.15 During the past 12 months, did {child’s name} use [herb #1, herb #2] for any of these reasons? Please say yes or no to each.
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
Medical treatments were not helping you
Medical treatments were too expensive
[modality] combined with medical treatments would help you
To stay healthy
You thought it would be interesting to try [modality]
To improve your energy
To Improve your immune function
To improve your physical performance
To improve your athletic or sports performance
To improve your sexual performance
To improve your concentration
To improve your memory
To improve your flexibility
To improve your muscle strength
Because [modality] was recommended by a medical doctor
Because [modality] was recommended by family, friends, or co-workers
Because the practitioner spends more time with you than medical doctors
Because prescription or over-the-counter drugs are too expensive
Because you can do [modality] on your own
Because you do not want to take prescription medication
Because [modality] is natural
Because [modality] focuses on the entire body and not just one part
Because the practitioner treats your entire body and not just one part
Because you wanted to try something different
Because using [modality] is how I was raised
[NEW]
PRT.17 Thinking about your use of [herb #1/herb #2], please tell me if any of these statements are true for {child’s name}. Please say yes or no to each.
Using [modality] has given {child’s name} a sense of control over your/his/her health?
Using [modality] has helped {child’s name} to relax?
Using [modality] has helped {child’s name} to reduce his/her stress level?
Using [modality] has motivated {child’s name} to eat healthier?
4a. In what ways are {child’s name} eating healthier? Say yes or no to each.
Eating more organic foods
Eating more fruits and vegetables
Eating more fish
Eating less saturated fats or trans fats
Eating less processed sugar or less foods make with corn syrup
Eating less red meat
Eating fewer calories
[for parent of child age 14+] Using [modality] has motivated {child’s name} to cut back or stop drinking alcohol?
(6) [for parent of child age 14+] Using [modality] has motivated {child’s name} to cut back or stop smoking cigarettes, cigars, or pipes?
(7) Using [modality] has motivated {child’s name} to exercise more regularly?
(8)Using [modality] has improved {child’s name} overall health and made him/her feel better?
(9)Using [modality] has given {child’s name} more hope for the future?
(10)Using [modality] has increased {child’s name} ability to focus?
(11)Using [modality] has made {child’s name} feel better emotionally?
(12)Using [modality] has made it easier for {child’s name} to cope with health problems?
(13)Using [modality] has improved {child’s name} outlook on life?
(14)Using [modality] has improved {child’s name} relationships with others?
(15)Using [modality] has improved {child’s name} self-confidence?
[NEW]
PRT.18 Of the following reasons, which was the most important reason for {child’s name} use of [herb #1/herb #2]? (display if more than one of (1,2,3) chosen in question PRT.16 above)
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem {child’s name} has now
(ask if 1,2, or 3 chosen in question PRT.16)
[NEW]
PRT.19 For what health problems or conditions did {child’s name} use [herb #1/ herb #2] [to keep from getting/to prevent another occurance/to treat or cure]?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.20; else go to PRT.21]
PRT.20 For which ONE of these health conditions did {child’s name} use [herb #1/ herb #2] the most?
_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using modality.
PRT.21 Did {child’s name} receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[2002 Q.]
PRT.22 How much do you think [herb #1/ herb #2] helped {child’s name} [condition]? Would you say a great deal, some, only a little, or not at all?
A great deal
Some
Only a little
Not at all
[2002 Q.]
PRT.23 NEW During the past 12 months, how important was {child’s name} use of [herb #1/ herb #2] in maintaining his/her health and well-being? Would you say very important, somewhat important, slightly important, or not at all important?
Very important
Somewhat important
Slightly important
Not at all important
PRT.24 DURING THE PAST 12 MONTHS, did you let any of the following CONVENTIONAL medical professionals know about {child’s name} use of [herb #1/ herb #2]? Please say yes or no to each.
D.O. or Doctor of Osteopathy
M.D. or Medical Doctor including specialists
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist including specialists
Psychologist/Social Worker
Pharmacist
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 Has {child’s name} EVER used homeopathic treatment?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY - DIETS)
HOM.2 DURING THE PAST 12 MONTHS, did {child’s name} use homeopathic treatment?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY - DIETS)
HOM.3 About how often do you buy homeopathic medicine for {child’s name}?
_____ times a day/week/month/year
HOM.4 And about how much did you spend the last time you bought homeopathic medicine for {child’s name}?
$ __________________
HOM.5 Has {child’s name} EVER seen a practitioner for homeopathic treatment?
(1) Yes
(2) No (GO TO PRT.3)
HOM.6 DURING THE PAST 12 MONTHS, did {child’s name} see a practitioner for homeopathic treatment?
(1) Yes
(2) No
[NEW]
PRT.3 Does {child’s name} currently use homeopathic treatment more, less, or about the same as he/she did one year ago?
1) More
2) Less
3) About the same
[NEW]
PRT.4 Compared to the past 12 months, does {child’s name} plan to use homeopathic treatment more, less, or about the same during the next 12 months?
1) More
2) Less
3) About the same
[NEW]
PRT.5 (Ask this for respondents who report having health insurance in core, else goto PRT.11)
(For respondents who said “no” to HOM.6 {seeing a practitioner} goto PRT.13)
During the past 12 months, were any of the costs of seeing a practitioner for homeopathic treatment covered by health insurance?
1) Yes (goto PRT.7)
2) No (goto PRT.11)
3) There was no cost for[modality](goto PRT.6)
[NEW]
PRT.6 During the past 12 months, how many times did {child’s name} see a practitioner for homeopathic treatment with no costs?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW]
PRT.7 During the past 12 months, did {child’s name’s} health insurance limit the number of visits to a practitioner or the dollar amount covered for homeopathic treatment?
1) Yes (goto PRT.7a)
2) No (goto PRT.9)
[NEW]
PRT.7a Which of these did {child’s name} health insurance limit: the number of visits, the dollar amount, or both?
1) number of visits (PRT.8)
2) dollar amount (PRT.8a)
3) both (PRT.8)
[NEW]
PRT.8 During the past 12 months, how many visits for {child’s name} to see a practitioner for homeopathic treatment were covered by health insurance?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 marked in PRT.7a, else goto PRT.9)
PRT.8a During the past 12 months, what dollar amount did {child’s name} health insurance cover for homeopathic treatment?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW]
PRT.9 How much was co-payment per visit for {child’s name} to see a practitioner for homeopathic treatment {fill for yes to PRT.7: for visits covered by insurance}?
$ __________________ (if #1 to PRT.7 goto PRT.10 else goto PRT.11)
[NEW]
PRT.10 During the past 12 months, did {child’s name} see a practitioner for homeopathic treatment more than was covered by health insurance?
1) Yes
2) No
[NEW]
PRT.11 During the past 12 months, how many times did {child’s name} see a practitioner for homeopathic treatment {if yes to PRT.10 fill: that was not covered by health insurance}?
____________________ (number of visits)
*If respondent does not know the exact number, instruct to take a guess
[NEW] (ask if #2 or #3 checked in PRT.7a, otherwise goto PRT.12)
PRT.11a During the past 12 months, were the costs for {child’s name} to use homeopathic treatment more than was covered by health insurance?
1) Yes (PRT.11b)
2) No (PRT.12)
[NEW]
PRT.11b During the past 12 months, how much more were the costs for {child’s name} to see a practitioner for homeopathic treatment than was covered by health insurance?
____________________ (amount in dollars)
*If respondent does not know the exact amount, instruct to take a guess
[NEW] (If no to PRT.7 skip this and goto PRT.13)
PRT.12 On average, what was the cost out-of-pocket for each of {child’s name} visits to a practitioner for homeopathic treatment {if yes to PRT.10 fill: that was not covered by insurance}?
$ __________________
$0-$499 *Enter 500 for $500 or more
[NEW]
PRT.13 During the past 12 months, did you or {child’s name} buy a self-help book or other materials such as a DVD, CD, or Video to learn about homeopathic treatment?
(1) Yes (goto PRT.14)
(2) No (goto PRT.15)
[NEW]
PRT.14 How much did you or {child’s name} pay for these materials?
$ ________________________
[NEW]
PRT.15 During the past 12 months, did {child’s name} use homeopathic treatment for any of these reasons? Please say yes or no to each.
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem {child’s name} has now
Medical treatments were not helping {child’s name}
Medical treatments were too expensive
[modality] combined with medical treatments would help {child’s name}
So {child’s name}would stay healthy
You or {child’s name} thought it would be interesting to try [modality]
To improve {child’s name} energy
To Improve {child’s name} immune function
To improve {child’s name} physical performance
To improve {child’s name} athletic or sports performance
To improve {child’s name} concentration
To improve {child’s name} memory
To improve {child’s name} flexibility
To improve {child’s name} muscle strength
Because [modality] was recommended by a medical doctor
Because [modality] was recommended by family, friends, or co-workers
Because the practitioner spends more time with {child’s name} than medical doctors
Because prescription or over-the-counter drugs are too expensive
Because you or {child’s name} can do [modality] on your own
Because you do not want {child’s name} to take prescription medication
Because [modality] is natural
Because [modality] focuses on the entire body and not just one part
Because the practitioner treats {child’s name} entire body and not just one part
Because you or {child’s name} wanted to try something different
Because using [modality] is how you or {child’s name} was raised
[NEW]
PRT.17 Thinking about your use of homeopathic treatment, please tell me if any of these statements are true for your child. Please say yes or no to each.
Using [modality] has given {child’s name} a sense of control over your/his/her health?
Using [modality] has helped {child’s name} to relax?
Using [modality] has helped {child’s name} to reduce his/her stress level?
Using [modality] has motivated {child’s name} to eat healthier?
4a. In what ways are {child’s name} eating healthier? Say yes or no to each.
Eating more organic foods
Eating more fruits and vegetables
Eating more fish
Eating less saturated fats or trans fats
Eating less processed sugar or less foods make with corn syrup
Eating less red meat
Eating fewer calories
[for parent of child age 14+] Using [modality] has motivated {child’s name} to cut back or stop drinking alcohol?
(6) [for parent of child age 14+] Using [modality] has motivated {child’s name} to cut back or stop smoking cigarettes, cigars, or pipes?
(7) Using [modality] has motivated {child’s name} to exercise more regularly?
(8)Using [modality] has improved {child’s name} overall health and made him/her feel better?
(9)Using [modality] has given {child’s name} more hope for the future?
(10)Using [modality] has increased {child’s name} ability to focus?
(11)Using [modality] has made {child’s name} feel better emotionally?
(12)Using [modality] has made it easier for {child’s name} to cope with health problems?
(13)Using [modality] has improved {child’s name} outlook on life?
(14)Using [modality] has improved {child’s name} relationships with others?
(15)Using [modality] has improved {child’s name} self-confidence?
[NEW]
PRT.18 Of the following reasons, which was the most important reason for using homeopathic treatment? (display if more than one of (1,2,3) chosen in question PRT.16 above)
To keep from getting a specific disease or health problem
To prevent another occurrence of a specific disease or health problem
To treat or cure a specific disease or health problem you have now
(ask if 1,2, or 3 chosen in question PRT.16)
[NEW]
PRT.19 For what health problems or conditions did you use homeopathic treatment [to keep from getting/to prevent another occurance/to treat or cure]?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.20; else go to PRT.21]
PRT.20 For which ONE of these health conditions did {child’s name} use homeopathic treatment the most?
_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using modality.
PRT.21 Did {child’s name} receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[2002 Q.]
PRT.22 How much do you think homeopathic treatment helped {child’s name} [condition]? Would you say a great deal, some, only a little, or not at all?
A great deal
Some
Only a little
Not at all
[2002 Q.]
PRT.23 NEW During the past 12 months, how important was your use of homeopathic treatment in maintaining {child’s name} health and well-being? Would you say very important, somewhat important, slightly important, or not at all important?
Very important
Somewhat important
Slightly important
Not at all important
PRT.24 DURING THE PAST 12 MONTHS, did you let any of the following CONVENTIONAL medical professionals know about {child’s name} use of homeopathic treatment? Please say yes or no to each.
D.O. or Doctor of Osteopathy
M.D. or Medical Doctor including specialists
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist including specialists
Psychologist/Social Worker
Pharmacist
INTERVIEWER CARD #1
150 HERB LIST
Combination Herb pill 5 HTP (5-Hydroxytryptophan) Acai Achillea (AKA Yarrowa) Aloe Vera American Ginseng (AKA Ginseng)
Angelica (AKA Dang Gui or Dong Quai)
Androstenedione Ashwagandha
Astragalus (AKA Huang Qi)
Bearberry (AKA Uva Ursi)
Bee Pollen
Bilberry
Bitter Gourd (AKA Bitter Mellon) Bitter Mellon (AKA Bitter Gourd) Black cohosh Black Mulberry berry or leaf (AKA Mulberry)
Blackroot Buckthorn Butterbur Cactus Carnitine Cascara sagrada Cassica senna (AKA Senna)
Cat’s Claw
Cayenne
Chasteberry (AKA Vitex) Chondroitin Coenzyme Q-10 Common Rue (AKA Rue or Ruta graveolens) Curcumin (AKA Turmeric) Conjugated Linolenic Acid (CLA) Cranberry (pills, gelcaps) Crataegus (AKA Hawthorn or Thornapple)
Creatine
Dandelion
Dang Gui (AKA Angelica or Dong Quai)
Devil’s Claw DHEA (Dehydroepiandrosterone) Digestive Enzymes (AKA Lactaid)
Dong Quai (AKA Angelica or Dang Gui)
Echinacea EGCG (pills) (AKA Green Tea extract) Elderberry Ephedra Evening primrose oil Feverfew Fiber or Psyllium (pills or powder) Fish oil or omega 3 or DHA fatty acid or EPA fatty acid supplements Flaxseed (Oil or Ground) in pill or capsule ( Fenugreek Garlic supplements (pills, gelcaps) Garcinia ( AKA Goat’s Thorn)
Ginger pills or gelcaps Ginkgo biloba Goat’s Thorn (AKA Garcinia)
Ginseng (also see American and Korean) Glucosamine Goji Berry in pills or capsules Goldenseal (AKA Hydrastis Guarana Grape Seed Extract Green tea pills (not brewed tea)(AKA EGCG) Hawthorn (AKA Crataegus or Thornapple)
Horehound
Horse chestnut Horny Goat Weed Huang Qi (AKA Astragalus)
Hypericum (AKA St. Johns Wort)
Jin Bu Huan
Korean (Asian) Ginseng (AKA Ginseng)
Kava kava
Lactaid (AKA Digestive Enzymes)
Lactobacillus (AKA Probiotics) Lavender tinctures or capsules (not oil)
Ligustrum (AKA Osha)
Linden flower (AKA Tilia)
You may choo Lecithin
Licorice root in pill or capsule Lutein Lycopene Maca Melatonin MSM (Methylsulfonylmethane) Milk thistle (AKA Silymarin) Mulberry berry or leaf (AKA Black Mulberry)
Noni juice or extract in capsules or pills
Olive Leaf extract
Oregano in pill or capsule
Osha (AKA Ligustrum)
Pau d’arco
Peppermint oil capsule
Pine bark extract (AKA Pycnogenol) Prebiotics Probiotics (AKA Lactobacillus) Puncture vine (AKA Tribulus terrestris)
Pycnogenol (AKA Pine bark extract)
Red yeast rice in pill or capsule
Rhodiola (AKA Roseroot)
Rose hips in pill or capsule
Roseroot (AKA Rhodiola) Rue (AKA Common Rue or Ruta graveolens) Ruta graveolens (AKA Common Rue or Rue) S-Adenosyl methionine (AKA SAM-e)
SAM-e (AKA S-Adenosyl methionine) Saw palmetto Senna (AKA Cassica senna) Siberian Ginseng (AKA Eleuthero, not a true Ginseng)
Silymarin (AKA Milk thistle)
Slippery elm (AKA Ulmus) Soy supplements or soy isoflavones St. John’s wort (AKA Hypericum) Stevia
Tilia (AKA Linden flower)
Tribulus Terrestris (AKA Puncture vine) Turmeric (Curcumin) Ulmus (AKA Slippery elm)
Uva Ursi (AKA Bearberry) Valerian Vitex (AKA Chasteberry)
Yarrow (AKA Achillea) Yohimbe or Yohimbine OTHER, Specify |
|
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | krs0 |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |