1. Choose the appropriate gender:
2. Choose the appropriate age category:
3. What do you prefer from the following when you need medical attention? (Check all appropriate)
4. Do you have a personal doctor that you visit when needing medical attention?
5. Your personal doctor specializes in:
6. Do you visit the same doctor for all your personal health needs?
7. How satisfied are you with the services of your current doctor? (Choose the level of satisfaction you gain from the services of your current doctor.)
8. Do you think your physician charges you appropriately for the services he/she provides?
9. Are you be willing to change hospitals/doctors on your doctor’s advice?
10. For seeking immediate medical attention, what would you prefer from the following in the first place?
11. When was the last time you visited a hospital?
12. Does your hospital provide you with adequate facilities to meet your personal requirements?
13. Is your hospital equipped with modern facilities for diagnosis and treatment?
14. Are you satisfied with the price levels charged by your hospital?
15. State why would you prefer hospital facilities over personal doctor or vice versa?