Health Care Opinion Survey


Hospital and health care opinion survey about the quality, affordability, availability, and preferences of customers.

Category : Health Care     (Browse All Categories)

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Here is the Health Care Opinion Survey Template template.


   
This is the questionnaire that deals with health care and your involvement in health care. Please take a few minutes to express your opinions about the availability and quality of health care in your community. Your answers are important to the success of this study.



Thank you for your assistance.
 
   
Please tell us the city, state (or territory), and country you live
   
 
   
Is there a difference in performance between the available hospitals in this area?
 
Yes
 
No
 
Not sure
 
   
Do you have a preferred hospital?
 
Yes
 
No
 
   
Is there a difference in the cost of the hospitals in this area?
 
Yes
 
No
 
Not sure
 
   
Do you receive pressure from other family members to get health care problems taken care of promptly?
 
Yes
 
No
 
Only sometimes
 
   
Do you feel comfortable judging the differences between hospitals in this area?
 
Yes
 
No
 
Not sure
 
   
Do you 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 many years have you lived in this community?
   
 
   
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 you regularly visit have equipment for modern diagnosis and treatment?
 
Yes
 
No
 
Not sure
 
   
Does the hospital have modern operating room facilities?
 
Yes
 
No
 
Not sure
 
   
How satisfied are you with the following:
Overall cleanliness of the hospital
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
   
Efficiency of nursing care
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
   
Friendliness and courtesy of staff
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
   
Convenience of location for you
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
   
Cost of health care
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
   
 
What kind of medical insurance coverage do you have?
 
None
 
Private
 
Employer sponsored
 
Medicaid
 
Medicare
 
Not sure
 
Other
    
 
   
 
How many times have you and any member of your family been to your doctor in the last year?
   
 
   
 
How many times have you visited a friend or loved one in the hospital in the last year?
   
 
   
 
How many times have you and other members of your family been a patient in a hospital in the last 3 years?
   
 
   
 
If quality of service is equal, which source of care would you prefer?
 
I would prefer to go to a walk-in clinic
 
I would prefer to go to my personal physician
 
I would prefer to go to the hospital emergency room
 
Other
    
 
   
 
If you or a member of your family have received medical care at another hospital while living in the [HOSPITAL] area, why did you choose the other hospital?
 
A specialist was available
 
Special hospital care required was not available in the local area
 
My physician practices there
 
More familiar with that hospital
 
Wanted a second opinion from another physician
 
Religious preference
 
Cost was too high in the local area
 
Other
    
 
   
 
When making health care decisions for your family, who is the primary decision maker?
 
Male (or husband)
 
Female (or wife)
 
Jointly (both husband and wife)
 
   
 
From your experience in the past, when you or a member of your family needs hospital care, who decides on the hospital?
 
You usually decide
 
You decide based on information from your physician
 
You and your physician decide together
 
Your physician decides based on information you provide
 
Your physician decides
 
Depends on the situation
 
   
 
What have you heard about the care patients receive at [Hospital]?
   
 
   
 
The last section of the questionnaire contains a series of questions about your demographic characteristics such as age and income. We are asking these questions in order to determine if various groups have different opinions and attitudes about hospital care. Please answer these personal questions. No one will ever associate these responses with your name.
 
   
 
Gender
 
Male
 
Female
 
   
 
Age
   
 
   
 
Age(s) of children living in your household: (Check all that apply)
 
< 12
 
12 - 18
 
18+

 
   
 
Marital status
 
Married
 
Widow(er)
 
Divorced or separated
 
Have never been married
 
   
 
Total household income (from all sources) before taxes for the year [Year]?
 
$25,000 or less
 
$25,000 - $49,999
 
$50,000 - $74,999
 
$75,000 - $99,999
 
$100,000 - $149,999
 
$150,000 and over
 
   
 
Highest level of formal education that you have completed.
 
High school graduate
 
College graduate
 
Completed graduate school
 
PHD
 
   
 
Primary occupation?
   
 
   
 
Spouse's primary occupation?
   
 
   
 
Thank you for your assistance.
 


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