Questionnaire

1. Who does the consultation you have an appointment relate to?

  • myself
  • mychild
  • another

2. What is the reason for the consultation?

  • acuteillness
  • control of chronic condition
  • other

3. How seriously do you assess the reason for your visit today?

0 (not serious )1 2 3 4 5 6 7 8 9 10 (very serious)

(Circle the number on the scale you think fits best)

4. How do you assess your health overall?

0 (bad) 1 2 3 4 5 6 7 8 9 10 (excellent)

(Circle the number on the scale you think fits best)

5. How much areyou willing to pay at maximum for the consultation youhave an agreement for today? (Tick onebox)

  • 0 DKK
  • 25 DKK
  • 50 DKK
  • 75 DKK
  • 100 DKK
  • 125 DKK
  • 150 DKK
  • 175 DKK.
  • 200 DKK
  • 250 DKK
  • 300 DKK
  • 350 DKK
  • 400 DKK
  • 450 DKK
  • 500 DKK
  • 600 DKK
  • 700 DKK
  • 800 DKK
  • 900 DKK
  • 1000 DKK or more

6. How certain or uncertain are you on your answer about how much you will pay?

  • very uncertain
  • uncertain
  • certain
  • verycertain

7. If you answered 0 DKK in question 5, what is the reason?

  • I would rather pay through taxes
  • It should be free of charge to see the doctor
  • I am against user fees out of principle reasons
  • I can not afford it
  • Other
  • Do not know

8. If you would have to pay[75DKK or 125 DKK, according to randomisation] for the consultation today, would you rather:

  • go to the emergency room if it was free? Yes/no
  • go to the out-of-hours service if it was free? /yes/no

9. Do you have a private health insurance, such as health insurance ”danmark” or

health insurance through your work?

Yes/No

10. How much time have you spent on transport to get to the doctor today?

(minutes)

11.How far is it from your residence to the clinic?

(Approx. kilometres)

12. How many times have you visited the doctor within the past year?

13. How many people live in your household including yourself?

14. How many people in your household are younger than 18 years old?

15. What is your highest attained education? (Tick one box)

  • No education
  • Primary education,1st-6th grade
  • Primary education,7th-10th grade
  • Upper secondary school leaving examination
  • Vocational education, e.g. clerk, carpenter, bricklayer, electrician, cook
  • Short cycle higher education, less than 3 years, e.g. financial economist, computer scientist
  • Bachelor education, 3-4 years, e.g. nurse, teacher
  • Master programmes or PhD, 5 years or more, for example, master's degree, Ph.D.
  • Other

16. What is your occupation? (Tick one box)

  • Unskilled worker
  • Skilled worker
  • Salaried employee without personnel responsibility
  • Salaried employee with responsibility for personnel
  • Self-employed
  • Co-working spouse
  • Conscript
  • Apprentice/student
  • Pensioner, early retired
  • Unemployed
  • Not in employment
  • Other

17. What is your personal annual income before taxes? (Tick one box)

  • Less than 100,000 DKK
  • 100,000 – 199,999 DKK
  • 200,000 – 299,999 DKK
  • 300,000 – 399,999 DKK
  • 400,000 – 499,999 DKK
  • 500,000 – 599,999 DKK
  • 600,000 – 699,999 DKK
  • 700,000 – 799,999 DKK
  • 800,000 – 899,999 DKK
  • 900,000 DKK or more
  • Will not disclose
  • Do not know

18. What is your household's annual income before taxes? (Tick one box)

  • Less than 100,000 DKK
  • 100,000 – 199,999 DKK
  • 200,000 – 299,999 DKK
  • 300,000 – 399,999 DKK
  • 400,000 – 499,999 DKK
  • 500,000 – 599,999 DKK
  • 600,000 – 699,999 DKK
  • 700,000 – 799,999 DKK
  • 800,000 – 899,999 DKK
  • 900,000 DKK or more
  • Will not disclose
  • Do not know