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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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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.
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