National Center for Complementary and Alternative Medicine (NCCAM)

NIH…Turning Discovery Into Health®

Follow NCCAM: Subscribe to our email update Subscribe to the NCCAM RSS feed Follow NCCAM on TwitterRead our disclaimer about external links Follow NCCAM on FacebookRead our disclaimer about external links

Menu
Complementary and Alternative Medicine: What People Aged 50 and Older Discuss With Their Health Care Providers

Appendix B: Survey Instrument

(ASK INSERT OF RESPONDENTS 50+)
Complementary and alternative medicine is a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. In the questions I ask you, I will refer to complementary and alternative medicine therapies as CAM (one word).

(SCRAMBLE ITEMS a-d)

CM-1. Have you used any of the following types of CAM in the past 12 months? Have you used (INSERT ITEM) in the past 12 months?

  • 1   Yes
  • 2   No
  • D  (DO NOT READ) Don't know
  • R  (DO NOT READ) Refused
  1. Herbal products or dietary supplements
  2. Massage therapy, chiropractic manipulation (ki-row-PRAC-tick), or other bodywork
  3. Mind/body practices, including hypnosis, meditation
  4. Naturopathy (na-tu-rop-A-thy), acupuncture (acu-PUNC-ture), or homeopathy (ho-ME-op-a-thy)
  5. Are there any other types of CAM that you have used? (SPECIFY____)

(ASK CM-1aa IF CM-1a-e=2, D OR R TO ALL)

CM-1aa. Have you EVER used any type of CAM?

  • 1   Yes
  • 2   No, never used any type
  • D  (DO NOT READ) Don't know
  • R   (DO NOT READ) Refused

(ASK CM-2 IF CM-1a-e=1 TO ANY) OR (IF CM-1aa=1)
(SCRAMBLE ITEMS a-d)

CM-2. What did you use CAM for? Do you use it (INSERT ITEM)?

  • 1   Yes
  • 2   No
  • D  (DO NOT READ) Don't know
  • R  (DO NOT READ) Refused
  1. To prevent illness or for overall wellness?
  2. To treat a specific health condition?
  3. (IF CM-2b is YES: To help reduce pain or treat painful conditions?)
  4. To supplement conventional medicine?
  5. For anything else (SPECIFY): _________________?

     

(SCRAMBLE ITEMS a-d)

CM-3. Have you ever discussed CAM with your…?

  • 1   Yes
  • 2   No
  • D  (DO NOT READ) Don't know
  • R  (DO NOT READ) Refused
  1. Physician
  2. Nurse or nurse practitioner
  3. Pharmacist
  4. Physician's assistant
  5. Any other health care provider (SPECIFY): ___________________

(ASK CM-4a-f if CM-3=2 TO ALL)
(SCRAMBLE ITEMS a-f)

CM-4. Which of the following are reasons why you did not talk with your health care provider about CAM? How about (INSERT ITEM)?

  • 1   Yes
  • 2   No
  • D  (DO NOT READ) Don't know
  • R  (DO NOT READ) Refused
  1. Didn't know you should
  2. Not enough time during office visit
  3. Your health care provider never asked
  4. You don't think your health care provider knows about the topic
  5. You weren't comfortable discussing it with your health care provider
  6. Your health care provider would have been dismissive or told you not to do it
  7. Any other reasons (SPECIFY): _________________

(ASK CM-5 IF CM-3=1 FOR ONE OR MORE ITEMS)

CM-5. Who brought up the subject?
(READ LIST) (ACCEPT ONE RESPONSE)

  • 1   You
  • 2   Your health care provider
  • 3   Relative/friend, or
  • 4   Someone else (SPECIFY):_______________
  • D  (DO NOT READ) Don't know
  • R  (DO NOT READ) Refused

(ASK CM-6 IF CM-3 =1 FOR ONE OR MORE ITEMS)
(ASK CM-6/B for each if CM-6=1)
(SCRAMBLE ITEMS)

CM-6. Has your health care provider ever discussed this specific information about CAM with you?

CM-6b. Would you like to discuss this information with your health care provider?

  • 1   Yes
  • 2   No
  • D  (DO NOT READ) Don't know
  • R  (DO NOT READ) Refused
  1. Safety of complementary and alternative medicine therapy
  2. Effectiveness of complementary and alternative medicine therapy
  3. How the complementary and alternative medicine therapy might interact with other medications or treatments you receive
  4. Referrals to complementary and alternative medicine practitioners
  5. What to use (herbs, acupuncture, massage, etc.)
  6. Advice on whether or not to pursue
  7. Where to get more information

(ASK CM-7 IF CM-1a-f=1 TO ANY) OR (IF CM-1aa=1)

CM-7. What is your primary source for information about CAM treatments? Is it…?
(SCRAMBLE ROTATE)
(READ LIST ACCEPT ONE RESPONSE)

  • 01   Pharmacist
  • 02   Family/friends
  • 03   Internet
  • 04   Nurses or Nurse Practitioner
  • 05   Nutritionist
  • 06   Health Food Stores
  • 07   Publications (please specify)
  • 08   Radio/TV
  • 09   Physician
  • 10   Physician Assistant
  • 11   Other (SPECIFY ___________)
  • D   (DO NOT READ) Don't know
  • R   (DO NOT READ) Refused

CM-8. How many different prescription medicines do you currently take?
(DO NOT READ LIST)

  • 1   Zero
  • 2   1
  • 3   2-3
  • 4   4-5
  • 5   More than 5
  • D  (DO NOT READ) Don't know
  • R  (DO NOT READ) Refused

(ASK CM-9 IF CM-1a-f=1 TO ANY) OR (IF CM-1aa=1)

CM-9. How many different over-the-counter medicines such as a multivitamin or calcium supplement, in addition to any CAM therapies, do you currently take?
(DO NOT READ LIST)

  • 1   Zero
  • 2   1
  • 3   2-3
  • 4   4-5
  • 5   More than 5
  • D  (DO NOT READ) Don't know
  • R  (DO NOT READ) Refused

* Note: PDF files require a viewer such as the free Adobe Reader.