This free survey is powered by QUESTIONPRO.COM
  1. Surveys
  2. 2011
  3. March
  4. H
  5. Health Care Questionnaire
0%
Exit Survey »
 
 
* Gender:
 
Male
 
Female
 
 
 
* Race:
 
American Indian/Native Alaskan
 
Asian
 
Black
 
White
 
Hispanic
 
Other
 

 
 
 
* Age:
   
 
 
 
* Education Level:
 
Less than High School
 
GED
 
High School Diploma
 
Trade School/Vocational School
 
Some College
 
Associate's Degree
 
Master's Degree
 
Bachelor's Degree
 
Master's Degree
 
Doctoral/Professional Degree
 
 
 
* Are you currently employed?
 
Yes
 
No
 
 
 
* Do you have health insurance?
 
Yes (if yes please see question 7)
 
No (if no please see question 8)
 
 
 
How long have you had health insurance? (Please be as specific as possible)
   
 
 
 
How long have you been without health insurance: (Please be as specific as possible)
   
 
 
 
* How would you rate your current health status?
 
Bad
 
Fair
 
Good
 
Very Good
 
Excellent

 
 
 
List any major health conditions you have:
   
 
Survey Software Powered by QuestionPro Survey Software