A health insurance survey questionnaire is normally filled by an individual and it contains information regarding that individuals’ health insurance. This type of survey questionnaire helps health organizations, insurance companies, and government health institutions to recognize what type of health insurance people have and what more do they require. It also provides important data regarding the number of people in a region, state, or country who have proper medical insurance.

Health Insurance Survey Questionnaire Sample

Name of the individual: ________________________________

Age: ______ Sex: _______  Occupation: ______________________

Address: ______________________________________

City: ________________ State: ___________________  Zip: _________________

Telephone: ____________________  Fax: ____________________________

Email: _________________________

Health Insurance plan: (if any) ___________________________________________

Insurance Policy Number: (if any) ___________________________________________

Q1. Are you aware of the various health insurance plans?

a)   Yes

b)   No

Q2. What is your current investment in your health insurance plan?

a)   Less than $2,000 annually

b)   $2,000 – $5,000 annually

c)   $5,000 – $10,000 annually

d)   More than $10,000 annually

Q3. Where did you obtain your health insurance from?

a)   Employer

b)   Spouse’s employer

c)   Other employer

d)   Reference of friends or family

e)   Reference of colleagues

f)    Directly from insurance company

g)   Through insurance agent

h)   Medicaid

i)     Medicare

j)    Both Medicaid and Medicare

k)   Don’t know

Q4. Which according to you is the most important aspect that every health insurance plan should cover?

a)   Hospital care

b)   Prescription drugs

c)   Preventive care

d)   Routine care

e)   Mental health

f)    Maternity

g)   Health specialists

h)   Choice of doctors

Q5. Which of the following cost feature attracts you the most in a health insurance plan?

a)   Low premium

b)   Low Co-pay

c)   Low Deductible

Q6. Which of the following benefits do you want through your health insurance plan?

a)   Publicly sponsored coverage

b)   $1,000 to $5,000 tax credit

c)   New public clinics

d)   Higher accessibility to medical practitioners


Health Surveys