Date: \_\_ \_\_/\_\_ \_\_/\_\_ \_\_   Time: \_\_ \_\_:\_\_ \_\_   Interviewer \_\_\_\_\_\_\_\_   Survey \# \_\_ \_\_ \_\_
  ------------------------------------- --------------------------- ------------------------------ --------------------------
  Location:                                                                                        
  \[ \]                                 GM-GOLD                     \[ \]                          WOODRAIL
  \[ \]                                 GM-GREEN                    \[ \]                          FAIRVIEW
  \[ \]                                 GM-BLUE                                                    

+-------------+------------+-------------+-------------+-------------+
| 1\. Agree   | Yes        | No          |             |             |
| to take     |            |             |             |             |
| survey      |            |             |             |             |
+=============+============+=============+=============+=============+
| \[IF NO     |            |             |             |             |
| STOP HERE.  |            |             |             |             |
| DO NOT      |            |             |             |             |
| CONTINUE\]  |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| 2\. Have    | Yes        | No          |             |             |
| you used    |            |             |             |             |
| the         |            |             |             |             |
| Internet    |            |             |             |             |
| for any     |            |             |             |             |
| purpose in  |            |             |             |             |
| the last    |            |             |             |             |
| month?      |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| 3\. Have    | Yes        | No          |             |             |
| you         |            |             |             |             |
| received or |            |             |             |             |
| sent email  |            |             |             |             |
| messages in |            |             |             |             |
| the last    |            |             |             |             |
| month?      |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
|             |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| 4\.         | Not at all | A little    | Moderately  | Very        |
| Overall,    |            | bit         | interested  | interested  |
| how         | interested |             |             |             |
| interested  |            | interested  |             |             |
| would you   |            |             |             |             |
| be to learn |            |             |             |             |
| more about  |            |             |             |             |
| how to use  |            |             |             |             |
| the         |            |             |             |             |
| Internet    |            |             |             |             |
| and email   |            |             |             |             |
| to          |            |             |             |             |
| communicate |            |             |             |             |
| with your   |            |             |             |             |
| doctor?     |            |             |             |             |
| Would you   |            |             |             |             |
| be...       |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+

+--------------+-------+--------------+---------+--------+-------+
| **Patient    |       |              |         |        |       |
| computer     |       |              |         |        |       |
| use** Survey |       |              |         |        |       |
| \# \_\_ \_\_ |       |              |         |        |       |
| \_\_         |       |              |         |        |       |
+==============+=======+==============+=========+========+=======+
|              |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| 1\. How      | Never | Less than    | Monthly | Weekly | Daily |
| often do you |       | Once per     |         |        |       |
| use a        |       | Month        |         |        |       |
| computer for |       |              |         |        |       |
| the          |       |              |         |        |       |
| following    |       |              |         |        |       |
| tasks?       |       |              |         |        |       |
|              |       |              |         |        |       |
| *\           |       |              |         |        |       |
| (Please      |       |              |         |        |       |
| check one    |       |              |         |        |       |
| response per |       |              |         |        |       |
| Item)*       |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To receive   | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| or send      |       |              |         |        |       |
| email        |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To order     | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| goods or     |       |              |         |        |       |
| services     |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To read      | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| about        |       |              |         |        |       |
| general      |       |              |         |        |       |
| health       |       |              |         |        |       |
| information  |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To read      | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| information  |       |              |         |        |       |
| about        |       |              |         |        |       |
| medications  |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To read      | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| about my     |       |              |         |        |       |
| health       |       |              |         |        |       |
| conditions   |       |              |         |        |       |
|              |       |              |         |        |       |
| (for         |       |              |         |        |       |
| example,     |       |              |         |        |       |
| blood        |       |              |         |        |       |
| pressure,    |       |              |         |        |       |
| diabetes, or |       |              |         |        |       |
| weight)      |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To track my  | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| health       |       |              |         |        |       |
| conditions   |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To track my  | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| diet or      |       |              |         |        |       |
| exercise     |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To find out  | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| about        |       |              |         |        |       |
| services     |       |              |         |        |       |
| offered by   |       |              |         |        |       |
| doctors or   |       |              |         |        |       |
| hospitals    |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To order     | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| prescription |       |              |         |        |       |
| medications  |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To email my  | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| doctor       |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| To look at   | \[ \] | \[ \]        | \[ \]   | \[ \]  | \[ \] |
| my medical   |       |              |         |        |       |
| record       |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
|              |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+
| Please use   |       |              |         |        |       |
| the space    |       |              |         |        |       |
| below to     |       |              |         |        |       |
| indicate     |       |              |         |        |       |
| other ways   |       |              |         |        |       |
| that you are |       |              |         |        |       |
| using the    |       |              |         |        |       |
| Internet     |       |              |         |        |       |
| and/or email |       |              |         |        |       |
| related to   |       |              |         |        |       |
| your health. |       |              |         |        |       |
+--------------+-------+--------------+---------+--------+-------+

+-------------+------------+-------------+-------------+-------------+
| Survey \#   |            |             |             |             |
| \_\_ \_\_   |            |             |             |             |
| \_\_        |            |             |             |             |
+=============+============+=============+=============+=============+
| 2\. If a    |            |             |             |             |
| web site    |            |             |             |             |
| were        |            |             |             |             |
| available   |            |             |             |             |
| for you to  |            |             |             |             |
| communicate |            |             |             |             |
| directly    |            |             |             |             |
| with your   |            |             |             |             |
| doctor and  |            |             |             |             |
| get other   |            |             |             |             |
| health      |            |             |             |             |
| i           |            |             |             |             |
| nformation, |            |             |             |             |
| [how        |            |             |             |             |
| i           |            |             |             |             |
| nterested]{ |            |             |             |             |
| .underline} |            |             |             |             |
| would you   |            |             |             |             |
| be in using |            |             |             |             |
| this web    |            |             |             |             |
| site to do  |            |             |             |             |
| any of the  |            |             |             |             |
| following   |            |             |             |             |
| tasks?      |            |             |             |             |
| *(Please    |            |             |             |             |
| check one   |            |             |             |             |
| response    |            |             |             |             |
| per item)*  |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
|             | Not at all | A little    | Moderately  | Very        |
|             |            | bit         | interested  | interested  |
|             | interested |             |             |             |
|             |            | interested  |             |             |
+-------------+------------+-------------+-------------+-------------+
| To email my | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| doctor      |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To send     | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| blood       |            |             |             |             |
| pressure or |            |             |             |             |
| blood sugar |            |             |             |             |
| data to my  |            |             |             |             |
| doctor      |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To order    | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| p           |            |             |             |             |
| rescription |            |             |             |             |
| medications |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To read     | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| about my    |            |             |             |             |
| health      |            |             |             |             |
| conditions  |            |             |             |             |
| (for        |            |             |             |             |
| example,    |            |             |             |             |
| blood       |            |             |             |             |
| pressure,   |            |             |             |             |
| diabetes,   |            |             |             |             |
| or weight)  |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To track my | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| diet and/or |            |             |             |             |
| exercise    |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To track my | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| health      |            |             |             |             |
| conditions  |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To look at  | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| my medical  |            |             |             |             |
| record      |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To make     | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| doctor      |            |             |             |             |
| a           |            |             |             |             |
| ppointments |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To see my   | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| pr          |            |             |             |             |
| escriptions |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To see my   | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| lab results |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To          | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| participate |            |             |             |             |
| in online   |            |             |             |             |
| support     |            |             |             |             |
| groups      |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To share my | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| medical     |            |             |             |             |
| information |            |             |             |             |
| with other  |            |             |             |             |
| family      |            |             |             |             |
| members     |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| To share my | \[ \]      | \[ \]       | \[ \]       | \[ \]       |
| medical     |            |             |             |             |
| information |            |             |             |             |
| with other  |            |             |             |             |
| doctors     |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| Are there   |            |             |             |             |
| other       |            |             |             |             |
| potential   |            |             |             |             |
| features or |            |             |             |             |
| uses of the |            |             |             |             |
| Internet or |            |             |             |             |
| email in    |            |             |             |             |
| regards to  |            |             |             |             |
| your health |            |             |             |             |
| care that   |            |             |             |             |
| you would   |            |             |             |             |
| find        |            |             |             |             |
| p           |            |             |             |             |
| articularly |            |             |             |             |
| useful?     |            |             |             |             |
| *(Please    |            |             |             |             |
| specify)*   |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+
| In relation |            |             |             |             |
| to using    |            |             |             |             |
| this web    |            |             |             |             |
| site to     |            |             |             |             |
| communicate |            |             |             |             |
| with your   |            |             |             |             |
| doctor and  |            |             |             |             |
| get other   |            |             |             |             |
| health      |            |             |             |             |
| i           |            |             |             |             |
| nformation, |            |             |             |             |
| do you have |            |             |             |             |
| any other   |            |             |             |             |
| comments or |            |             |             |             |
| concerns?   |            |             |             |             |
+-------------+------------+-------------+-------------+-------------+

+-----------+---------+-----------+------+-----------+-----------+
| Survey \# |         |           |      |           |           |
| \_\_ \_\_ |         |           |      |           |           |
| \_\_      |         |           |      |           |           |
+===========+=========+===========+======+===========+===========+
|           |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| 3\. Where | My home | Family or | Work | Public    | Other     |
| do you    |         | friend's  |      | library   | places    |
| access    |         | home      |      |           |           |
| the       |         |           |      |           |           |
| Internet? |         |           |      |           |           |
|           |         |           |      |           |           |
| *(circle  |         |           |      |           |           |
| all that  |         |           |      |           |           |
| apply)*   |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
|           |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| 4\. The   |         |           |      |           |           |
| next      |         |           |      |           |           |
| questions |         |           |      |           |           |
| ask basic |         |           |      |           |           |
| in        |         |           |      |           |           |
| formation |         |           |      |           |           |
| about     |         |           |      |           |           |
| you.      |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| a\. In    |         |           |      |           |           |
| general   |         |           |      |           |           |
| how would |         |           |      |           |           |
| you rate  |         |           |      |           |           |
| your      |         |           |      |           |           |
| health?   |         |           |      |           |           |
| (circle   |         |           |      |           |           |
| one)      |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| 1-        |         |           |      |           |           |
| excellent |         |           |      |           |           |
| 2-very    |         |           |      |           |           |
| good      |         |           |      |           |           |
| 3-good    |         |           |      |           |           |
| 4-fair    |         |           |      |           |           |
| 5-poor    |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| b\. Do    |         |           |      |           |           |
| you have  |         |           |      |           |           |
| any       |         |           |      |           |           |
| chronic   |         |           |      |           |           |
| illness   |         |           |      |           |           |
| (for      |         |           |      |           |           |
| example:  |         |           |      |           |           |
| diabetes, |         |           |      |           |           |
| high      |         |           |      |           |           |
| blood     |         |           |      |           |           |
| pressure, |         |           |      |           |           |
| or        |         |           |      |           |           |
| asthma)?  |         |           |      |           |           |
| (circle   |         |           |      |           |           |
| one)      |         |           |      |           |           |
| 1-yes     |         |           |      |           |           |
| 2-no      |         |           |      |           |           |
| 3-unsure  |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| c\. What  |         |           |      |           |           |
| year were |         |           |      |           |           |
| you born? |         |           |      |           |           |
| \_\_ \_\_ |         |           |      |           |           |
| \_\_ \_\_ |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| d\. What  |         |           |      |           |           |
| is your   |         |           |      |           |           |
| gender?   |         |           |      |           |           |
| (circle   |         |           |      |           |           |
| one)      |         |           |      |           |           |
| 1-male    |         |           |      |           |           |
| 2-female  |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| e\. What  |         |           |      |           |           |
| is your   |         |           |      |           |           |
| race?     |         |           |      |           |           |
| (circle   |         |           |      |           |           |
| [all]{.u  |         |           |      |           |           |
| nderline} |         |           |      |           |           |
| that      |         |           |      |           |           |
| apply)    |         |           |      |           |           |
| White     |         |           |      |           |           |
| Black     |         |           |      |           |           |
| Asian     |         |           |      |           |           |
| Other:    |         |           |      |           |           |
| \_\       |         |           |      |           |           |
| _\_\_\_\_ |         |           |      |           |           |
| \_\_\_\_\ |         |           |      |           |           |
| _\_\_\_\_ |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| f\. Are   |         |           |      |           |           |
| you of    |         |           |      |           |           |
| Hispanic  |         |           |      |           |           |
| or        |         |           |      |           |           |
| Latino(a) |         |           |      |           |           |
| e         |         |           |      |           |           |
| thnicity? |         |           |      |           |           |
| (circle   |         |           |      |           |           |
| one) yes  |         |           |      |           |           |
| no don\'t |         |           |      |           |           |
| know      |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| **g. What |         |           |      |           |           |
| is your   |         |           |      |           |           |
| highest   |         |           |      |           |           |
| level of  |         |           |      |           |           |
| e         |         |           |      |           |           |
| ducation? |         |           |      |           |           |
| (circle   |         |           |      |           |           |
| one)**    |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| > 1-Did   |         |           |      |           |           |
| > not     |         |           |      |           |           |
| >         |         |           |      |           |           |
|  graduate |         |           |      |           |           |
| > high    |         |           |      |           |           |
| > school  |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| > 2-High  |         |           |      |           |           |
| > school  |         |           |      |           |           |
| > gra     |         |           |      |           |           |
| duate/GED |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| > 3-T     |         |           |      |           |           |
| rade/some |         |           |      |           |           |
| > college |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| >         |         |           |      |           |           |
| 4-College |         |           |      |           |           |
| >         |         |           |      |           |           |
|  graduate |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| > 5-Post  |         |           |      |           |           |
| >         |         |           |      |           |           |
|  graduate |         |           |      |           |           |
| > degree  |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| **h. What |         |           |      |           |           |
| is your   |         |           |      |           |           |
| annual    |         |           |      |           |           |
| household |         |           |      |           |           |
| income?   |         |           |      |           |           |
| (circle   |         |           |      |           |           |
| one)**    |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| > 1-Less  |         |           |      |           |           |
| > than    |         |           |      |           |           |
| >         |         |           |      |           |           |
|  \$20,000 |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| > 2       |         |           |      |           |           |
| -\$20,000 |         |           |      |           |           |
| > -       |         |           |      |           |           |
| >         |         |           |      |           |           |
|  \$39,999 |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| > 3       |         |           |      |           |           |
| -\$40,000 |         |           |      |           |           |
| > -       |         |           |      |           |           |
| >         |         |           |      |           |           |
|  \$59,999 |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+
| > 4       |         |           |      |           |           |
| -\$60,000 |         |           |      |           |           |
| > or more |         |           |      |           |           |
+-----------+---------+-----------+------+-----------+-----------+

**Thank you for completing the survey! Please return it to the box in
the reception area.**

**\
**

             **Patient computer use** Survey \#\_\_ \_\_ \_\_                                                                                              
  ---------- ---------------------------------------------------------------------------------------------- ---------------------------------------------- ----------------------------------------------------------------------
  ***1.***   ***The following is a list of possible reasons why you do not use the Internet or email.***                                                   
  *** ***    ***(Please check all that apply)***                                                                                                           
             a\.                                                                                            \_\_                                           I do not have access to a computer
             b\.                                                                                            \_\_                                           I do not have access to a computer that is connected to the Internet
             c\.                                                                                            \_\_                                           I do not know how to use the Internet
             d\.                                                                                            \_\_                                           I do not know how to use email
             e\.                                                                                            \_\_                                           I do not feel comfortable using the Internet
             f\.                                                                                            \_\_                                           I do not feel comfortable using email
             g\.                                                                                            \_\_                                           I cannot afford to pay for an Internet connection
             h\.                                                                                            \_\_                                           I can't see well enough to use a computer
             i\.                                                                                            \_\_                                           I do not know how to type
             j\.                                                                                            \_\_                                           Other reason (please specify)
                                                                                                                                                            
  ***2.***   ***The next questions ask basic information about you.***                                                                                     
  a\.        **In general how would you rate your health? (circle one)**                                                                                   
                                                                                                            1-excellent 2-very good 3-good 4-fair 5-poor   
  b\.        **Do you have any chronic illness (for example: diabetes, high blood pressure, or asthma)?**                                                  
                                                                                                            (circle one) 1-yes 2-no 3-unsure               
  c\.        **What year were you born?**                                                                                                                  
                                                                                                            \_\_ \_\_ \_\_ \_\_                            
  d\.        **What is your gender? (circle one)**                                                                                                         
                                                                                                            1- Male 2- Female                              
  e\.        **What is your race? (circle [all]{.underline} that apply)**                                                                                  
                                                                                                            White Black Asian Other: \_\_\_\_\_            
  f\.        **Are you of Hispanic or Latino(a) ethnicity? (circle one)**                                                                                  
                                                                                                            yes no don\'t know                             
  g\.        **What is your highest level of education? (circle one)**                                                                                     
                                                                                                            1                                              Did not graduate high school
                                                                                                            2                                              High school graduate/GED
                                                                                                            3                                              Trade/some college
                                                                                                            4                                              College graduate
                                                                                                            5                                              Post graduate degree
  h\.        **What is your annual household income? (circle one)**                                                                                        
                                                                                                            1                                              Less than \$20,000
                                                                                                            2                                              \$20,000 - \$39,999
                                                                                                            3                                              \$40,000 - \$59,999
                                                                                                            4                                              \$60,000 or more
                                                                                                                                                           *Thank you - Please return survey to box at front desk.*