Your responses will be reviewed by a clinical research associate at McMaster University's Division of Gastroenterology.

Your responses will be kept strictly confidential and used for research purposes only, so please be as accurate as possible.

Take this patient resource satisfaction survey and tell use what you value most. The entire survey should take about 2-3 minutes to complete.

   
 
 
 
 
     
     
       
     
         
           
Demographics
 
What is your date of birth?
   
What is your gender? male female
   
In what country do you live?
   
In what state/ province do you live? (US and CDN residents)
 
 
Which of these symptoms is your MAIN gastrointestinal complaint?
Upper abdominal pain (pain above the navel/ stomach pain)
Nausea or vomiting or abdominal bloating with visible distention (noticeably swollen belly)
Heartburn (pain or burning radiating up to the throat) or acid regurgitation (sour taste/ stomach contents coming back up
I don't have any of these symptoms
 
Has your doctor EVER told you that you have ANY of the following?
PLEASE CHECK ALL THAT APPLY.
Gastro-esophageal reflux disease (GERD) or Reflux
Gastritis (stomach inflammation) Esophagitis
Dyspepsia (indigestion) Peptic ulcer disease (Ulcers)
Helicobacter pylori infection Chronic cough
Gallstones Pancreatitis
Lactose intolerance Celiac disease
Stomach cancer Irritable bowel syndrome (IBS)
Dysmotility (motility disorder) other:
My gastrointestinal symptoms have not yet been diagnosed
I have not seen a doctor about my symptoms
INFORMATION RESOURCE USE
1. Please indicate which of the following you consider your primary (MAIN) resource for information concerning your GASTROINTESTINAL (GI) disorder.
Family doctor/ general practitioner (GP)
Gastroenterologist/ GI specialist
Family or friends
Patient information pamphlets or booklets
The Internet
Medical books or articles
radio or television broadcasts or newspaper or magazine articles
None, I haven't used any information resources to learn more about my GI condition. skip to question 4
2. Please indicate your level of satisfaction with each of the following as an information resource for your GI condition.
Information resource
very satisfied
somewhat satisfied
not very satisfied
NEVER USED
Family doctor/ GP
Gastroenterologist/ GI specialist
Patient information pamphlets
The Internet
Medical books or articles
Radio/ television/ newspapers/ magazines
 
3. Which of the following most accurately describes how often or when you tend to use patient information resources?
Weekly
Monthly
Biannually/ once or twice in a six month period
Yearly/ once a year
Only when my symptoms are getting worse
Only when I first started to experience symptoms/ around the time I was diagnosed
 
4. How would you rate each of the following types of patient information or patient resources?
 
very important
important
somewhat important
not too important
not at all important
General information about my condition (symptoms, tests, causes, common treatments).
Information about new treatments.
Information about the consequences of my condition/ how it may affect my life now and in the future.
Support/ discussion groups/ contact with others who have what I have.
 
Please provide a contact e-mail address (optional)
 
e-mail address:
 



     
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