Access to Health Care example

This is an example Access to Health Care survey. This survey includes questions like:

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1) Are you male or female?
2) What is your age?
3) Do you have health insurance?
  • Yes
  • No (go to question 5)
4) What type of health insurance coverage do you carry?
  • Employer provided
  • Self-purchased
  • Medicaid or State provided
  • Medicare
  • Other:
5) What is the MAIN reason you do not have health insurance?
  • Employer does not provide health insurance.
  • Can't afford to purchase health insurance.
  • Can't afford dependent coverage.
  • Other:
6) Do you receive routine physical examinations or health check-ups?
  • Yes (go to question 8)
  • No
7) What is the MAIN reason you do not receive regular physical examinations?
  • No insurance coverage
  • Insurance does not cover routine physical exams
  • Unable to afford co-pay
  • No time
  • No doctor
  • Not needed. I'm healthy
  • Other:
8) Do you have a family doctor or routine health care provider?
  • Yes (go to question 10)
  • No
9) Which of the following reasons apply for why you do not have a routine health care provider?
  • Never needed a doctor.
  • No HMO providers in my area.
  • No preferred providers in my area.
  • No insurance.
  • Don't like primary care physician assigned.
  • Other:
10) Where do you go when you need to see a doctor about a non-emergency health problem or illness?
  • Regular physician
  • Emergency Room
  • Urgent Care Clinic
  • Community Health Clinic
  • Other:
11) Please tell us the biggest obstacle you face for access to health care.
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