1. Do you currently keep copies of your health records (either on paper or your computer) or would like to?

Yes   No

2. Do you want comprehensive health information to be readily available in an emergency?

Yes   No

3. Do you manage or monitor your child's or parent's healthcare or want to be more involved in it?

Yes   No

4. Do you want to be notified if a loved one visits an emergency room?

Yes   No

5. Do you have a chronic illness?

Yes   No

6. Are your medical records scattered among several doctors' offices?

Yes   No

7. Do you believe that if your doctor had more comprehensive health information about you and your family, that
   the treatment plan and outcomes will be better?

Yes   No