Complementary Alternative Therapy (CAM) Use Survey

Complementary Alternative Therapy (CAM) Use Survey
Definition: A broad set of healthcare practices, therapies, and modalities used in combination with conventional Western medical, surgical, and prescription therapies. (Please do not include any identifiable information)
Date
MonthDayYear
Today's Date
Email
example@example.com
Age
Ex:23
Gender
Are you or someone you know a current or past recipient of cancer treatments (chemo &/or radiation)?
YesNo
How long were the treatments for?
1-4 months5-8 months9-12 months> 1 year
What side effects of conventional cancer treatments were experienced?
Nausea/VomitingFatigueWeight gain/Weight LossDepression/AnxietyPain/DiscomfortConstipation/DiarrheaInsomnia/RestlessnessForgetfulness (a.k.a. "Chemo brain")Other
Was some form of CAM (Complementary Alternative Medicine or Treatment) used to help relieve treatment side effects (past or present)? Check all that apply:
YesNoVitamins/Minerals/Herbal Supplements to include, but not limited to pills, powders, tinctures, brewed teas, gels, lotions, creams, bath salts, or any other treatment applied to the skin, in water, or taken by mouth.AcupunctureAromatherapyMeditationPrayerYogaReikiOther
If "Yes" to CAM use, what side effects did it help relieve?
Nausea/VomitingFatigueWeight Loss/Weight GainDepression/AnxietyPain/DiscomfortConstipation/DiarrheaInsomnia/RestlessnessForgetfulness ("Chemo Brain")Other
Why was the decision made to used these complementary therapies? (Check all that apply)
Help manage side effects of cancer treatmentsHope and/or cureMaintain quality of lifeMaintain some control over their body and decision-makingHelp boost immune systemN/AOther
Type of cancer?
BreastProstateLungPancreasLeukemia/BloodKidneyLiverStomachColonBrainOtherThroatThyroidOvarian/Uterine
At any time during cancer treatments), was time spent in the hospital?*
YesNo
Do you believe that you are directly responsible for your health?
YesNo
*(Survivors Only) Do you continue to use some form of CAM during remission OR, have begun using it post treatment as a form of self-care?
Yes, I continue to use CAMNo, I no longer use CAMDidn't use CAM during treatments but I do now
Thank you for your participation in this survey! Your responses will be used to shed light on the value added to the cancer patient's quality of life, help to encourage open communication between patients and providers regarding CAM use thus making it easier for patients to make health choices without feeling dismissed or devalued.
Peace & Health :-)
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