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| What city/ county do you live in? Do they want to screen by zip codes (as more accurate) for areas that we can serve today PLUS the mountain communities? This is missing the Denver Metro suburbs like Aurora, Broomfield, Westminster, Littleton, Lafayette, etc… |
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| What best describes your employment status? |
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| How involved are you in your household’s health care and health insurance decisions? (e.g. choosing your health carrier, your insurance plan, your physician(s), interacting with insurance company, etc.) |
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| Do you or any of your relatives work in any of the following types of companies / departments? |
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| What role do you play when it comes to decisions related to the overall Health of your household? |
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| How would you describe your current health status and that of your household?
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| Members of my household currently have the following conditions:
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| Do you have other conditions not listed? Please write them in the box. | | |
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| Do any of your household members have other conditions not listed? Please write them in the box. | | |
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Lifestyle and Prevention:
In the last 12 months, which of the following have you done? (Select all that apply) |
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Alternative and Complementary Medicine and Approaches:
In the last 12 months, which of the following have you used or done as part of maintaining your health or treating a condition? (Select all that apply) |
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Medicine, Tobacco, Alcohol, and Recreational Drug Use:
In the last 12 months, which of the following have you used? (Select all that apply) |
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| On average, how many drinks per week do you consume? |
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| On average, how often do you use tobacco? |
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Perception on what drives “good health” in an individual:
Please rate how much you agree or disagree on each of the following statements in terms of being important to driving “good health” in an individual.
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Greatest Challenges to maintaining health:
Please rate how much you agree or disagree on each of the following statements in terms of being a challenge to getting and staying healthy.
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Influencers of views towards health and wellness:
Please rate how much you agree or disagree on the following statements in terms of how they influence your views towards health and wellness.
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| What role do you play in your household when it comes to decisions related to Health Care? |
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| Do you currently have a doctor, nurse practitioner, physician assistant, or other health care professional you consider to be your primary care provider (PCP)? |
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| If answered yes in the previous question, your current PCP is a |
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| How satisfied are you with your current Primary Care Provider? |
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| In the last 12 months, which of the following have you done? (Select all that apply) |
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| The last time you were injured or got sick, did you go see a doctor? |
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| If you answered no in previous question, what is the main reason you did not go see a doctor? |
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| If answered yes in the previous question, the last time you were sick or injured after seeing a doctor, did you delay or skip treatment? |
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| If you answered Yes in the previous question, what is the main reason why you delayed / skipped treatment? |
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| On a scale of 1 to 5 (1 being “Not at all likely” and 5 being “Very likely”), how likely are you to follow treatment plan exactly as the doctor orders?
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| On a scale of 1 to 5 (1 being “Not at all likely” and 5 being “Very likely”), how likely are you to take prescription medications strictly according to a label?
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| On a scale of 1 to 5 (1 being “Not at all likely” and 5 being “Very likely”), how likely are you to take over the counter medications strictly according to a label?
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| Please rate how important is each of the following attributes to you when choosing a primary health care provider.
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| Please rate how much you agree or disagree on the following statements.
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Importance of innovative health information technologies:
Please rate how important each attribute to you in terms of using technology in health care.
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| How do you prefer to engage and communicate with your health care provider to manage your health? |
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| What is your current health insurance status? |
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| Why don’t you have a health insurance? Please rate how much you agree or disagree on the following:
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| Why don’t you have a health insurance? Please indicate your other reasons, if any. Otherwise, write N/A. | | |
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| How do you feel about health insurance in general? Please rate how much you agree or disagree on the following statements. I feel that health insurance is…
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| What is your coverage status (i.e. who is covered under this carrier/ plan)? |
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