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Coventry Questionnaire

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

About your education

About your health

About health information and advice

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