Coventry Questionnaire

Consent

I confirm

1. I consent that I have read and understand the Participant Information Sheet (see left), date 08/09/2008 (version 1), for the above study.

2. I consent that I would like to participate in this questionnaire study.

3. I consent that I understand that my participation is voluntary and that I am free to withdraw at any time.

About you

1. Are you

2. How old are you

3. To which of these ethnic groups do you consider yourself to belong

About your education

4. Are you an undergraduate or a postgraduate student

5. Which faculty are you in

6. Are you a full-time or part-time student

7. Are you a Home or EU or International student

About your health

8. How many times did you visit the GP last year

9. Overall how would you rate your health during the past 4 weeks

10. Do you have a long-term physical or mental health problem or disability which requires regular contact with the health service

About health information and advice

The next question asks about how you access health information and advice

Please tick all which apply to you

Face to face contact with a health professional

Family and friends

The Internet

Telephone contact with a health professional

N/A

11. Which of the following would you use when you want general health information and advice

12. Which of the following would you use when you want health information and advice about minor illnesses

13. Which of the following would you use when you want health information and advice about serious illnesses

About Online Health Information and Advice

The next few questions ask about your use of online health information and advice.

Please tick all that apply

I have used the Internet

14. To interact with web doctor or health professional you have not met

15. To approach family doctor or other known health professionals

16. For self-help activities

17. To order medicines or health products

18. To read about basic health or illness

19. To decide whether to see a doctor

20. To prepare for an appointment

21. To look up information after an appointment

22. To read about a specific illness or drug

23. To deal with an ongoing medical condition, like diabetes or high blood pressure

24. Because I haven’t had time to visit a physician

25. Did the information you got online affect any of your decisions about health treatments or the way you take care of yourself

26. Have you ever talked to your GP about health information you found on the Internet

In my opinion online health information and advice

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

No Opinion

27. Allows me to go into appointments informed

28. Undermines the doctors and nurses

29. Is reassuring

30. Is confidential

31. Is quick

32. Is easy

33. Is convenient

34. Is good for sensitive issues

35. Is untrustworthy

36. Is confusing

37. Makes me anxious

Your views about the proposed online self-assessment system.

This online system (available via the Student Health Centre website) would allow patients to anonymously self assess their need to seek care through responding to questions that are generated in response to the symptoms that you are experiencing.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

No opinion

38. I think I could get a good understanding of my medical problem via this system.

39. I think I’d be able to identify important symptoms well enough to use this system.

40. The use of the necessary equipment seems difficult to me.

41. This system could save time for the GPs and nurses.

42. I don’t like that there will be no physical contact during this system.

43. I think the system will be a convenient form of health-care delivery for me.

44. I think I would use this system.

45. This system will allow me to make informed decisions about seeking care.

46. I think this system will reassure me.

47. I think this system will only be suitable for minor illnesses.

48. I don’t think this system will increase access to care for me.

49. The use of this system will not threaten the confidentiality of my medical data.

50. I think this system will prevent me from seeing a GP or nurse.

51. I think this system will prevent unnecessary appointments by allowing me to self care.

52. This system will be useful if my usual GP or nurse is unavailable.

53. I think this system will be good for sensitive issues.

54. This system will mean that urgent cases will get appointments sooner.

55. This system will justify me making an appointment with the GP or nurse.

Thank you so much for taking time to complete this questionnaire. If you wish to change your answers, please do so before submitting your questionnaire. By submitting your questionnaire you are consenting to take part in this research project. Once again, thank-you for sparing your time to complete and submit this questionnaire.

Privacy notice

This form is anonymous. No data which personally identifies you is collected on the form, and the data you provide is used solely for research purposes.

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at infocompliance@warwick.ac.uk.

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Coventry Questionnaire

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