OMB No. 0925-0530
Exp. Date 06/30/07
SAMPLE: SELF-ADMINISTERED QUESTIONNAIRE
Do you talk to your health care providers about complementary and alternative medicine?
The National Center for Complementary and Alternative Medicine at the National Institutes of Health is interested in getting your input about how people communicate with their health care providers about complementary and alternative medicine (CAM). Your responses are confidential and anonymous. Thank you for sharing your thoughts.
Please read the following statements:
Talking to your providers about CAM use helps them be fully informed and your partner in health care.
Some CAM approaches can have an effect on conventional medicine. Talking with your health care providers will help ensure coordinated and safe care.
Giving your health care providers a full picture of what you do to manage your health helps you stay in control.
Some CAM therapies may be beneficial to your health, but can interact with conventional medications.
1. Which statement do you like the most? _______________
What do you like about it?____________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
2. Which statement do you like the least? ________________
What don’t you like about it? ____________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
DEMOGRAPHICS The following questions are for statistical purposes only.
3. Do you discuss CAM with your doctor/provider?
Yes No
4. What is your gender?
Female Male
5. What is your age?
50-55 56-60 61-65 66-70 71-75 75+
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
NIH
Project Clearance Branch
6705 Rockledge Drive
MSC 7974
Bethesda, MD 20892-7974
ATTN: PRA (0925-0520).
Do not return the completed form to this address.
| File Type | application/msword |
| File Title | Do you talk to your health care providers about complementary and alternative medicine |
| Author | LMIT-BPS |
| Last Modified By | Suzanne Niemeyer |
| File Modified | 2007-06-15 |
| File Created | 2007-06-15 |