Health Care Survey Questionnaire

A health care survey questionnaire consists of questions pertaining to health care plans, different types of health care facilities etc for adults, children, and elderly. Filled by individuals, this type of survey questionnaire offers information and details of those enrolled with healthcare plans. A health care survey questionnaire also throws light on the prevailing condition of the health care system and industry in a particular region or state.

Health Care Survey Questionnaire Sample

Name of the individual: ________________________________

Age: ______ Sex: _______  Occupation: ______________________

Address: ______________________________________

City: ________________ State: ___________________  Zip: _________________

Telephone: ____________________  Fax: ____________________________

Email: _________________________

Healthcare plan: (if any) ___________________________________________

Q1. Where do you visit regularly for medical care?

a)   Hospital

b)   Private clinic

c)   Health clinic

d)   General practitioner

e)   Others: __________________________

Q2. Do you have a personal doctor or family physician?

a)   Yes

b)   No

c)   Don’t know

Q3. Do you have medical insurance? If yes, then specify the type of insurance.

a)   Yes

b)   No

c)   Medical insurance: ________________________________________________

Q4. In the last 5 years, did you face any difficulty in obtaining proper health care? If yes, please mention the difficulties faced.

a)   Yes

b)   No

c)   Difficulties faced: _______________________________________________

Q5. How satisfied are you with your current health care system and provider?

a)   Extremely satisfied

b)   Very satisfied

c)   Dissatisfied

d)   Very dissatisfied

e)   Neutral

f)    Don’t know

Q6. What medical treatments have you undergone in the previous year?


Q7. How accessible is your healthcare provider?

a)   Can be easily accessed

b)   Face a little difficulty

c)   Not easily accessible

d)   Not accessible at all

e)   Can’t say

Q8. What changes do you suggest in the current health care system that will benefit you?


Category: Survey Questionnaire

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