A health care consumer questionnaire is one that is obtained from a consumer in order to understand the health care preference of the consumer. The questionnaire aims to identify the inclination of the consumer towards a particular health care and the reasons for the same.

This questionnaire is made use of by a health care organization that wants to understand the consumer preferences and changing trends in health care needs.

Sample Health Care Consumer Questionnaire

Name of the consumer:-

Address of the consumer:-

Email address of the consumer:-

Contact number of the consumer:-

Note – Please note that the personal information provided by you will be strictly confidential and will not be shared with any other person under any circumstances by us.

1. Please specify the location of your residence?


2. Are there sufficient health care organizations present in your vicinity?

a) Yes

b) No

3. Is there a specific health care organization that you always prefer to visit when you are in need of medical services? Please specify the name and location of the health care organization?


4. How frequently do you visit a health care unit for getting a routine examination done?

a) Monthly

b) Quarterly

c) Half yearly

d) Yearly

5. Do you visit a health care unit on the basis of personal evaluation undertaken by you?

a) Yes

b) No

6. On what basis do you judge a health care unit from the following factors?

a) Good doctors

b) Good ambience

c) Convenience and proximity

d) Cheaper than other health care units in the vicinity

e) Modern facilities and equipments

7. Do you always ensure to visit the same health care unit for your medical needs?

a) Yes

b) No

8. Do you think you will recommend the health care unit you prefer and always visit to all your friends and relatives based on your experience?

a) Yes

b) No