Name

Email

Date of Birth

Home address including postcode

1. Are you completing this questionnaire for yourself?
YesNo

2. Can you read and understand English ?
YesNo

3. After you have been to the doctor or to the hospital, you can check if the encounter has been recorded and what was discussed. Do you agree this is a good reason to have access to your records?
YesNo

4. There may be an instance when accessing your medical records online, whereby you read some information that could be shocking or upsetting. What do you do if this happens and you cannot speak to your doctor/nurse immediately? Please tick all options that apply.
Not view the test results but wait until you see the doctor/nursePanic and get worked upLook at the NHS website for self-helpWait and contact the practice the next working daySpeak to a friend or family member whom you trustContact 111 to get further informationGo to A&E for further helpOther

5. You see a new letter has arrived in your electronic health record. You open up the letter to find it is about another patient in the practice. What do you do?
Read it and divulge details to othersInform the practiceStay quiet and not tell anybody about itOther

6. Would it upset you if you read something somebody else has said about you with regards to your health? This does NOT mean others can see your record without your permission.
NoYes – I don’t want this information kept in my recordYes – You should not believe what others sayYes – This could destroy our relationshipI do not understand what this question meansDon’t knowOther

7. Do you feel you understand what Record Access means?
YesNoOther