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Women's Health Care Survey Template

Women's Health Care Survey Template offers questions about preferences of a physician, physician evaluation, and service offering evaluation. This sample can be edited by the survey maker according to the required details about the women's health care. Some of the question examples of this questionnaire are "Do you personally have a private physician?", "Where is your personal physician located?", "Do you visit the same physician for most of your personal medical needs?", et al.


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?


What kind of physician is he/she?

Where is your personal physician located?
Do you use the same physican for most of your personal medical needs?
How likely are you to switch hospitals on your physician’s advice (from your preferred hospital)?
Hypothetically, if you need to be hospitalized, would you choose your physician or your hospital first?
Age category:
Have you been hospitalized for OB/Maternity?
When were you last hospitalized for OB/Maternity?
Where were you last hospitalized for OB/Maternity care?
Have you ever been hospitalized for anything other than OB/Maternity?
If yes: When were you last hospitalized for non-OB care?
Where were you last hospitalized for non-OB care?
Are you employed outside the home?
If employed outside the home; what is your approximate income?
What is your approximate annual household income:
Zip code:
Which type of medical insurance do you have?
Area:
Marital Status:
Number of children delivered:
Thank you.

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