Complementary Alternative Therapy (CAM) Use Survey

A survey for healthcare providers to document whether cancer patients used complementary alternative therapies during or after treatment.

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Date

Age

Gender

Are you or someone you know a current or past recipient of cancer treatments (chemo &/or radiation)?

Yes No

How long were the treatments for?

Less than 6 months 6-12 months 1-2 years More than 2 years

What side effects of conventional cancer treatments were experienced?

Nausea Fatigue Hair Loss Pain 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

Acupuncture Meditation/Mindfulness Herbal Supplements Massage Therapy Yoga None

If "Yes" to CAM use, what side effects did it help relieve?

Nausea Fatigue Pain Anxiety/Stress Other

Why was the decision made to use these complementary therapies? (Check all that apply)

Recommended by doctor Personal research Friend/family recommendation Dissatisfaction with conventional treatment

Type of Cancer

Breast Lung Prostate Colorectal Other

At any time during cancer treatments, was time spent in the hospital?*

Yes No

Do you believe that you are directly responsible for your health?

Yes No Somewhat

(Survivors Only) Do you continue to use some form of CAM during remission, or have you begun using it post-treatment as a form of self-care?

Yes No

Thank you for completing this survey

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