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How old are you?
 
14 y/o
 
15 y/o
 
16 y/o
 
17 y/o and up
 
 

Do you smoke?
 
Yes
 
No
 
If yes, who initiated you?
 
 
 

Who initiated you to smoke?
 
Family
 
Friends
 
No one
 
Others
 
 
 

Do you drink?
 
Yes
 
No
 
 

Do you feel comfortable judging the differences between hospitals in this area?
 
Yes
 
No
 
Not sure
 
 

Do you generally receive care from the same hospital?
 
Yes
 
No
 
Not sure
 
 

Can you be helpful to friends who are having difficulty making section of a hospital?
 
Yes
 
No
 
Not sure
 
 

How satisfied are you with the skill and competency of the staff?
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
 

Does the hospital have equipment for modern diagnosis and treatment?
 
Yes
 
No
 
Not sure
 
 

Does the hospital have modern operating room facilities?
 
Yes
 
No
 
Not sure
 
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