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
- Herbal products or dietary supplements
- Massage therapy, chiropractic manipulation (ki-row-PRAC-tick), or other bodywork
- Mind/body practices, including hypnosis, meditation
- Naturopathy (na-tu-rop-A-thy), acupuncture (acu-PUNC-ture), or homeopathy (ho-ME-op-a-thy)
- 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
- To prevent illness or for overall wellness?
- To treat a specific health condition?
- (IF CM-2b is YES: To help reduce pain or treat painful conditions?)
- To supplement conventional medicine?
- 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
- Physician
- Nurse or nurse practitioner
- Pharmacist
- Physician's assistant
- 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
- Didn't know you should
- Not enough time during office visit
- Your health care provider never asked
- You don't think your health care provider knows about the topic
- You weren't comfortable discussing it with your health care provider
- Your health care provider would have been dismissive or told you not to do it
- 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
- Safety of complementary and alternative medicine therapy
- Effectiveness of complementary and alternative medicine therapy
- How the complementary and alternative medicine therapy might interact with other medications or treatments you receive
- Referrals to complementary and alternative medicine practitioners
- What to use (herbs, acupuncture, massage, etc.)
- Advice on whether or not to pursue
- 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
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