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.

Women's Health Care Survey Template

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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 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 physicians 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.