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  1. Surveys
  2. 2013
  3. December
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  5. Untitled
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How many times have you and any member of your family been to your doctor in the last year?
   
 
 
 
How many times have you and other members of your family been a patient in a hospital in the last 3 years?
   
 
 
 
When making health care decisions for your family, who is the primary decision maker?
 
Male (or husband)
 
Female (or wife)
 
Jointly (both husband and wife)
 
 
 
Sex of person completing this questionnaire:
 
Male
 
Female
 
 
 
Age of person completing this questionnaire:
   
 
 
 
Age(s) of children living in your household: (Check all that apply)
 
< 12
 
12 - 18
 
18+

 
 
 
Marital status of person completing this questionnaire:
 
Married
 
Widow(er)
 
Divorced or separated
 
Have never been married
 
 
 
What was your total household income (from all sources) before taxes for the year [Year]?
 
$25,000 or less
 
$25,000 - $49,999
 
$50,000 - $74,999
 
$75,000 - $99,999
 
$100,000 - $149,999
 
$150,000 and over
 
 
 
Please indicate the highest level of formal education that you have completed.
 
High school graduate
 
College graduate
 
Completed graduate school
 
PHD
 
 
 
What is your primary occupation?
   
 
 
 
What is your spouse's primary occupation?
   
 
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