Additional file 1
Title: Patient questionnaire
Description: Questionnaire used to assess the urgency of an ED visit and to explore factors associated or not with this assessment.
PATIENT QUESTIONNAIRE
Emergency Department: ______
1) Date of visit : _____/____/______
2) Day of the week: ………………………
3) Time of arrival: ______: ______
CATEGORIZATION CONDUCTED BY THE TRIAGE NURSE
Immediately after the admittance
4) Presenting complaint: ______
5) Could this problem be taken care of by a primary care physician? q Yes q No
6) Why? ______
CHARACTERISTICS OF THE ED VISIT
7) Patient’s complaint(s), symptom(s), or other reason(s) for this ED visit (Use patient’s own words) ______
8) Mode of arrival:
q Ambulance q Public service (police, social service) q Own transport q Other: ______
9) Who made the decision to come to the ED?
q My general practitioner
q Myself
q A member of my family
q My employer
q Other ______
10) How much time has passed since symptoms began and the decision to come to the ED?
q One day
q Less than a week
q More than a week (note the period:______)
11) Did you try to speak to a primary care provider before coming to the ED? q Yes q No
12) What made you choose to come to the ED today? (multiple answers possible with ranking 1 to X):
q My health problem require immediate attention
q My health problem is too urgent to wait to see a primary care provider
q My problem was too serious or to complex to see a primary care provider
q My problem require x-rays, laboratory testing or treatment
q I did not want my primary care provider to know about my health problem
q I’m afraid
q I'm in a hurry
q My primary care provider was unavailable.
q I need a medical certificate (administrative reasons)
q It is easier for me to come to the ED
q Not applicable (The patient does not choose to come)
q Other ______(1 word).
13) Do you suffer from any chronic disease or condition? q Yes q No
14) On an urgency scale from 1 to 20, how would you rate your current urgency?___/20
utilization of health care services
15) Currently, did you have a primary care provider? q Yes q No
16) What do you do when you have health problems?
q I usually see my primary care provider
q I see other physician
q I usually prefer self-medication without seeing the primary care
q I prefer to come to the hospital
q Other ______
17) In the past year, how many times have you consulted your primary care provider?
q None q 1 or 2 times q 3-5 times q more than 5 times
18) In the past year, how many times have you been treated at an ED?
q None q 1 or 2 times q 3-5 times q more than 5 times
PATIENT INFORMATION
19) Patient’s age: ______
20) Sex: q Male q Female
21) Employment status: q Employed q Unemployed
22) Currently, what is your primary medical insurance? / 23) What is your supplementary health insurance?q None / q None
q «Sécurité sociale» (French health insurance) / q Private supplementary health insurance
q CMU (French health insurance designed specifically to individuals and families with low incomes and resources) / q Supplementary CMU (French supplementary health insurance designed specifically to individuals and families with low incomes and resources)
1