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.

As you know, you should NOT provide patient names or any other 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.
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

 

2. What is your relationship to the patient(s)? Check all that apply.
1. Primary care provider (e.g. physician, nurse practitioner)
2. Medical Specialist
3. CAM Provider
4. Other:   Please specify

 

3. (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.

 


Thank You!