Women's Health Care Survey Template

Women’s Health Care survey including physician choice factors, physician evaluation, service offering evaluation.



   
We are conducting a survey regarding some issues about Women's health care. The survey takes approximately 20 minutes.
 
   
 
Do you personally have a private physician?
 
Yes
 
No
 
Don't know
 
   
If you answered yes, please answer the following four questions.


What kind of physician is he/she?

 
Pediatrician
 
OB/GYN
 
Family/General Practice
 
Internist
 
Other
    
 
   
 
Where is your personal physician located?
 
Area 1
 
Area 2
 
Area 3
 
Area 4
 
Area 5
 
Area 6
 
Area 7
 
   
 
Do you use the same physican for most of your personal medical needs?
 
Yes
 
No
 
   
 
How likely are you to switch hospitals on your physician’s advice (from your preferred hospital)?
 
Very likely
 
Somewhat likely
 
Somewhat unlikely
 
Very unlikely
 
Not sure
 
   
 
Hypothetically, if you need to be hospitalized, would you choose your physician or your hospital first?
 
Physician
 
Hospital
 
Not sure
 
Depends
 
   
 
Age category:
 
< 18
 
18 - 30
 
31 - 44
 
45 - 54
 
55 & over
 
   
 
Have you been hospitalized for OB/Maternity?
 
Yes
 
No
 
   
 
When were you last hospitalized for OB/Maternity?
 
In the past year
 
1-5 years ago
 
Over 5 years ago
 
   
 
Where were you last hospitalized for OB/Maternity care?
 
Hospital 1
 
Hospital 2
 
Hospital 3
 
Hospital 4
 
Hospital 5
 
   
 
Have you ever been hospitalized for anything other than OB/Maternity?
 
Yes
 
No
 
   
 
If yes: When were you last hospitalized for non-OB care?
 
During past year
 
1-5 years ago
 
Over 5 years ago
 
   
 
Where were you last hospitalized for non-OB care?
 
Hospital 1
 
Hospital 2
 
Hospital 3
 
Hospital 4
 
Hospital 5
 
   
 
Are you employed outside the home?
 
Full time
 
Part time
 
Not employed
 
Other
    
 
   
 
If employed outside the home; what is your approximate income?
 
Less than $20,000
 
$20,000 - $40,000
 
$40,001 - $60,000
 
Over $60,000
 
   
 
What is your approximate annual household income:
 
Less than $30,000
 
$30,000-$50,000
 
$50,001-$70,000
 
Over $70,000
 
Not sure
 
   
 
Zip code:
   
 
   
 
Which type of medical insurance do you have?
 
Self pay (no insurance)
 
Medicare/Medicaid
 
Third party (insurance company)
 
All HMO or PPO
 
Other
    
 
   
 
Area:
 
Area 1
 
Area 2
 
Area 3
 
Area 4
 
Area 5
 
Area 6
 
Area 7
 
   
 
Marital Status:
 
Married
 
Single
 
Divorced
 
Widowed
 
Refuse to answer
 
   
 
Number of children delivered:
 
None
 
1-2
 
3-5
 
Over 5
 
   
 
Thank you.
 

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