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1.
What is your sex?
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2.
Of what age group are you?
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3.
Do you have a family doctor?
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4.
If your answer was no have your ever had a family doctor?
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5.
Do you have medical insurance?
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6.
What kind of insurance do you have?
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7.
If you answered no to #6 have you ever had medical insurance?
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8.
If you had medical insurance, and lost it please tell us the cause.
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9.
How many people live in your household?
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10.
Are you?
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11.
Are you?
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12.
In your last visit to the hospital do you feel that you or your family member was treated right?
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13.
If your answer was no tell us what happened?
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14.
What was the name of the hospital you visited and what state was it in?
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15.
Was there a person or persons that gave you great care, what was their name and what was their title?
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16.
How far is it to your nearest hospital?
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17.
Do you know how to find your hospitals rating?
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18.
On your last visit to a hospital to you feel that the Nurse or the Doctor or both really listened to your problem?
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19.
Would you return to the same hospital if you could go to another hospital?
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20.
Do you think that doctors really care about you?
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21.
Do you feel that nurses really care about you?
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22.
I would ask that you give us your email address for the survey; you will not get junk mail. If you do not wish to that is alright.
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