Form 1 survey

OMB No. 0925-0530-03

Exp. Date 10/31/2010

Public reporting burden for this collection of information is estimated to average 8 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

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regarding this burden estimate or any other aspect of this collection of information, including

suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,

Bethesda, MD 20892-7974, ATTN: PRA (0925-0530). Do not return the completed form to this address.

Complementary and Alternative Medicine (CAM) Use

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CAM is a group of diverse medical and health care systems, practices, and products that are not currently considered to be part of conventional medicine. Examples of CAM include such products and practices as herbal supplements, meditation, chiropractic manipulation, and acupuncture.

e’re interested in learning about how you as a health care professional communicate with your patients about CAM use. Your responses will be confidential and anonymous (see http://nccam.nih.gov/tools/privacy.htm). Thank you for sharing your thoughts.

1. Do you ask patients about their CAM use? Yes No

2. How important do you think it is to discuss CAM therapy use with your patients? (Circle one response.)

   1. Not at all important

   2. Not too important

   3. Somewhat important

   4. Very important

3. Please estimate the percentage of your patients with whom you discuss complementary and alternative medicine.

a. 0-25%

b. 26-50%

c. 51-75%

d. 76-100%

4. Do your patient history forms include a question about CAM use? ­­­­­­­­­­­­­­­­­­­ Yes No

5. When you discuss CAM use, who usually initiates the conversation?

1. Me/My staff

2. Patients

3. N/A

6. How comfortable are you discussing CAM with patients?

1. Very comfortable

2. Somewhat comfortable

3. Somewhat uncomfortable

4. Very uncomfortable

7. Do any of the following keep you from talking more often with your patients about CAM? (Select all that apply.)

1. Not enough time during office visit.

2. It’s not a high priority for me.

3. I don’t want to encourage CAM use.

4. I don’t know enough about CAM to feel comfortable discussing it.

5. Other:______________

8. How familiar are you with the National Institutes of Health’s National Center of Complementary and Alternative Medicine’s Time to Talk materials? [Show graphic of the toolkit]

1. Have never seen them before

2. Have glanced at them

3. Are aware of the materials, but don’t use them in my practice

4. Have read over the materials and use them in my practice

Please look over the materials and then answer the following questions.

8. Please take a moment to review the Ask fact sheet. Then circle the number that best represents your response to each of the following statements.

	Strongly Agree				Strongly Disagree
The information in the fact sheet would be helpful for me and my staff.	1	2	3	4	5
After reading this fact sheet, I am encouraged to bring up CAM use with my patients.	1	2	3	4	5
I would make this fact sheet available to my staff.	1	2	3	4	5

9. Please take a moment to review the Tell fact sheet. Then circle the number that best represents your response to each of the following statements.

	Strongly Agree				Strongly Disagree
The fact sheet is easy for patients to understand.	1	2	3	4	5
The information in the fact sheet is helpful for patients.	1	2	3	4	5
After reading this fact sheet, patients will be encouraged to bring up CAM use with me.	1	2	3	4	5
I would make these fact sheets available to my patients	1	2	3	4	5

10. Please take a moment to review the wallet card. Then circle the number that best represents your response to each of the following statements.

	Strongly Agree				Strongly Disagree
The wallet is easy for patients to understand and complete.	1	2	3	4	5
By using this wallet card, patients will be encouraged to bring up CAM use with me.	1	2	3	4	5
I would make these wallet cards available to my patients	1	2	3	4	5

11. Having looked at the materials now, how likely are you to incorporate the Time to Talk materials into your practice?

1. Very likely

2. Somewhat likely

3. Neutral

4. Somewhat unlikely

5. Very unlikely

If you selected unlikely, please state why:

_______________________________________________________________________________

12. What other information or materials would help you in discussing CAM use with your patients?

________________________________________________________________________________

________________________________________________________________________________

_____________________________________________________________­­­­­­­­­­­___________________

Please complete the following demographic questions:

14. My gender is:

1. Male

2. Female

15. My race/ethnicity is:

Ethnicity:

• Hispanic or Latino

• Not Hispanic or Latino

Race:

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

Thank you for helping us by completing this questionnaire.

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