Patient & Health and Medical Practitioners Experiences Using Complementary & Alternative Medicine (CAM) to Treat Medical Conditions

Are you a Patient or Health Consumer?

Are you a Medical or Health Practitioner?

Are you both? (Patient/Health consumer and Medical or Health Practitioner)

For Patients or Health consumer :

1. Have you ever used any of the following therapies or remedies for the treatment of a disease or health condition, such as diabetes, asthma, depression, HIV/AIDS, Parkinson's disease, or cancer? (check all that apply)

Treatment :
Vitamins and/or nutritional supplements
A special diet like a whole foods, macrobiotic, vegan, vegetarian diet
Medicinal herbs, plants, or teas
Remedies or practices associated with a particular culture like      Chinese medicine, Ayurveda, Native American healing, etc.
Homeopathic remedies
Meditation, guided imagery, visualization, hypnosis
Manual therapies like massage or acupressure
Energy therapies like Reiki or therapeutic touch
Prayer, spirituality or religion
Other: Please specify   

What condition have you treated for :     Yes No

Section two:
The next set of questions is about the serious condition or disease for which you used the treatments indicated above. If you used these therapies for the treatment of more than one serious illness, please answer the questions for each serious illness for which these treatments were used.
For each disease or health condition identified above for which you have you used Complementary and Alternative therapies/treatments, please answer the follow-up questions below. Be as specific as possible:

1(a) For the disease or health condition listed above, what types of Complementary and Alternative therapies did you use?

1(b) To help provide us with a clear understanding of your illness, please classify it below.  

Specific type:

2. When did you first learn you had this disease or health condition (approximate date)?

3. How did you learn you had this disease or health condition?

4. Were you diagnosed by a health professional?
Yes No

5. Was this health professional a conventional medical doctor or a CAM practitioner?

6. How long after your diagnosis did you begin CAM therapies for your condition?

7. How would you characterize the severity of your illness at the time of your medical diagnosis?

Please provide supporting detail, if available, to support the classification above? (such as kind and stage of cancer, type of epilepsy and frequency of seizures, intensity and distribution of pain or rash, etc.)

8. Which of the following were important considerations in your decision to seek the above named therapies or treatments? (check all that apply)

Select your decision :
Less invasive/risky than conventional therapy
More cost-effective than conventional therapy
Dissatisfaction with the results of conventional therapy
Successful reports from others with the same condition
Suggestion from someone I trust
Convincing media coverage/research

9. How long and how consistently have you used the above therapies?

10. Are these therapies being used independently or in conjunction with conventional treatments, such as antibiotics, chemotherapy, radiation, prescription medications, etc.?

11. If being used independently, were you receiving conventional medical treatments prior to beginning CAM therapies?

12. If so, for how long and consistently were you seeking conventional therapies?

13. What was the change, if any, in your disease or health condition resulting from using the above named therapies?

13(a). Did the above mentioned change include a change in the disease progress or state (e.g. remission, cure, improvement in lab tests or markers)
Yes No
Please describe:

13(b). Did the above mentioned change include a change in symptoms
Yes No

If yes, please specify:
1. Reduced pain
Yes No
2. More energy
Yes No
3. Fewer side effects from other treatments
Yes No
4. Greater mobility
Yes No
5. Increased Appetite
Yes No
6. Decreased Appetite
Yes No
7. Other:

14. What was the timeline for the improvements described above?

If you would like us to work with you to consider the suitability of your experience for a case report in our study, please provide us with contact information (email address or other information). If you are eligible and want to become a study participant, we will ask you to sign a consent form before collecting, with your written permission, detailed data on your case. You may also submit the form above anonymously indicating that you are not currently interested in participating.

15. Age

16. Biological Sex
Male Female Other
17. Year of birth : 19

18. Ethnicity

19. Education

20. Marital status

21. Children (number)

22. Household income

23. Mother´s education

24. Father´s education

25. State of residence

26. What language are you most comfortable conversing in?
Other (please specify)

For Medical or Health Practitioner :

Please use this form if you are a patient or medical provider and would like to report your experience using CAM for serious illness. You may provide us with contact information so we can communicate with you about your case, or you may submit this form anonymously indicating that you are not currently interested in participating.

Should you choose to supply contact information, please DO NOT provide patient names or any other personal identifying information.

1. Have you been in any way involved with the care of patients with serious illness who appear to have benefited from any of the following alternative/complementary (CAM) therapies? Please indicate yes or no for each.


2. On the basis of what evidence are you drawing your conclusions to the above questions? (check all that apply)

Select conclusions :
Patient feedback
Physical Observations
Improvement in test results or other markers

3. Have you been in any way involved with the care of patients with serious illness who appear to have seen no improvement in their condition or whose condition has worsened with the use of the above mentioned alternative/complementary (CAM) therapies? Please explain.

3s.(optional) Please give a brief anonymous description of the most notable successes you have witnessed in the use of the above mentioned treatments providing no patient identification information. Please include illness treated without providing any identifying information for the patient.

4. What is your relationship to the patient(s)? (Check all that apply.)

Select your relationship to the patient
Primary care provider (e.g. physician, nurse practitioner)
Medical Specialist
CAM Provider