Screen Survey, Patient

Please fill out and submit this form to make a report of 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.
Section One: These questions are about remedies and treatments that are not typically prescribed by medical doctors. We are interested in therapies used specifically for the treatment of serious diseases.
1. Have you ever used any of the following therapies or remedies for the treatment of a serious disease/condition, such as diabetes, asthma, depression, HIV/AIDS, Parkinson's disease, or cancer?
Vitamins and/or nutritional supplements	Yes No
A special diet like a whole foods, macrobiotic or vegetarian diet	Yes No
Medicinal herbs, plants, or teas	Yes No
Acupuncture	Yes No
Remedies or practices associated with a particular culture like Chinese medicine, Ayurveda, Native American healing, or Curanderismo	Yes No
Homeopathic remedies	Yes No
Movement techniques like yoga, tai chi, or qi gong	Yes No
Meditation, guided imagery, visualization, hypnosis	Yes No
Chiropractic	Yes No
Manual therapies like massage or acupressure	Yes No
Energy therapies like Reiki or therapeutic touch	Yes No
Prayer, spirituality or religion	Yes No
Other: Please specify

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.
1(a) For what serious disease/condition have you used Complementary and Alternative therapies or treatments for? Please be as specific as possible: 1(b) For the serious disease/condition listed above, what types of Complementary and Alternative therapies did you use? Please be as specific as possible: 1(c) To help provide us with a clear understanding of your illness, please classify it below. Use the definitions page for help if needed.
Category:	Specific Type:

If you choose "Other" category, please describe: 2. When did you first learn you had this disease/condition (approximate date)?
3. How did you learn you had this disease/condition?
Were you diagnosed by a health professional?	Yes No
If no, how did you learn you had this disease/condition?
4. Why did you seek the above named therapies or treatments? (e.g., doctor recommended it, heard about it by word of mouth)

5. What was the change, if any, in your disease/condition resulting from using the above named therapies?
A. Change in the disease progress or state (e.g. remission, cure, improvement in lab tests or markers)
Yes No
Please describe:
B. 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. Appetite	Yes No
6. Other:



Section Three


1. When were you born?

2. In what country were you born?
3. How would you describe your ethnicity?
4. Among the following choices, how would you classify yourself? (Check all that apply) 1. American Indian or Alaskan Native 2. Asian or Pacific Islander 3. Black (not of Hispanic Origin) 4. Hispanic 5. White (not of Hispanic Origin) 6. Other or Unknown
5. Gender Male Female Other
6. What language are you most comfortable conversing in? English Spanish Other (please specify)
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 approved by the Columbia University College of Physicians & Surgeons Institutional Review Board before collecting, with your written pemission, detailed data on your case. You may also submit the form above anonymously indicating that you are not now interested in participating. Thank You!