We are interested in learning more about access to medical care. Please take a few minutes to answer the short survey below.
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Personal Info:
Name: (optional)
City:
State:
Country:
Age: (optional)
Job Title:
Survey:
1. On average, how often do you visit a medical facility for a routine, non-emergency examination?
More than 2 times a year 2 times a year 1 time a year Less than 1 time a year Never
2. On average, how often do you visit a medical facility for emergency care?
More than 10 times a year Between 5-10 times a year Between 2-4 times a year 1 time a year Never
3. On average, how far do you travel to reach a medical facility?
0-1km 2-6km 7-12km 13-25km 26-50km More than 50km
4. How far do you travel to reach a major medical facility (hospital, other than a local clinic)?
0-15km 16-30km 31-60km 61-100km 101-200km More than 200km
5. What percentage of your families (including You, Spouse/Partner and/or Children) total yearly salary/resources is spent on the costs of medical care?
0-10% 11-20% 21-30% 31-50% 51-75% More than 75%
6. On average, how would you rate your health?
Excellent Very good Good Fair Poor
7. On average, how would you rate the medical care you receive?
8. How often have you been declined medical treatment for any of your family members (including You, Spouse/Partner and/or Children)?
More than 10 times a year Between 5-10 times a year Between 2-4 times a year Once a year Never
9. If you have been declined medical care what was the reason?
Could not afford health care costs No transportation to health care facility Insufficient number of medical personnel Appropriate medical personnel not present Other (specify)
10. How often do you take prescription drugs?
Daily More than 10 times a year Between 5-10 times a year Between 2-4 times a year One time a year Never
11.How often have you been declined prescription drugs for any of your family members (including You, Spouse/Partner and/or Children)?
12. If you have been declined prescription drugs what was the reason?
Could not afford prescription drugs No transportation to prescription drugs facility No prescription drugs available No prescription drug facility Other (specify)
13. Overall how would you describe your access to adequate medical care?
14. Is medical insurance available to you?
Yes No Do not know
15. Do you have medical insurance?
16. If you do NOT have medical insurance what is the reason?
Unavailable Too expensive Voluntarily decline Other
17. Does your country have a national medical insurance system?
18. What aspects do you like the most regarding your medical services?
19. What aspects do you like the least regarding your medical services?
