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Questionnaire template

Health Data Use Preferences

Measures patients' awareness of, and preferences and safeguards for, the use of their health data for care, research and planning.

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Healthcare · Patient consent. All Healthcare templates

Questions in this template

What You Know Today

  1. We would like to hear your views on how your health information is used and how you want to be asked about it. This survey records your preferences only; it does not change any consent you have already given.

  2. How aware are you of how we use the health information we hold about you?

    Choose one:

    • Very aware
    • Somewhat aware
    • Not very aware
    • Not at all aware

  3. How have you been told about the use of your health information?

    Choose any that apply:

    • Spoken explanation by staff
    • Printed leaflet or poster
    • Patient portal or app
    • Website
    • Consent or registration form
    • I have not been told

  4. Did you know you can withdraw your permission for some uses of your information?

    Choose one:

    • Yes
    • No
    • Not sure

Your Preferences

  1. Would you be willing for your health information to be used for each of these purposes?

    • Sharing between the professionals involved in your care
    • Research, with your name and identifying details removed
    • Research that needs identifying details, with ethics approval
    • Planning and improving local health services
    • Helping companies develop health products

    For each row: choose one:

    • Yes
    • No
    • Not sure

  2. For uses beyond your own care, how would you prefer to be asked?

    Choose one:

    • Ask me each time
    • Ask me once, and let me change my mind later
    • Use it unless I opt out
    • Do not use it beyond my own care

  3. How would you prefer to record or change your choices?

    Choose one:

    • Online portal or app
    • In person
    • By post
    • By phone

Trust and Safeguards

  1. How much do you trust us to keep your health information secure?

    Choose one:

    • Not at all
    • A little
    • Moderately
    • A lot
    • Completely

  2. How important is each of these protections to you?

    • Removing names and identifying details
    • Independent oversight of who uses the data
    • Being able to see who has accessed my record
    • Public reports on how data are used
    • Keeping data stored in this country

    For each row: choose one:

    • Not important
    • Somewhat important
    • Very important

  3. What is your main concern, if any, about the use of your health information?

    Choose one:

    • A data breach or leak
    • Use for profit
    • Being identified
    • Effects on insurance or employment
    • I have no concerns
    • Other

  4. What is that concern?

    Condition: Only when Other was selected

    Open answer

About You

  1. What is your age?

    Choose one:

    • 18-34
    • 35-54
    • 55-74
    • 75 or older
    • Prefer not to say

  2. Is there anything else you would like to tell us about how your health information is used?

    Open answer