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1.
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Are you an American or American
resident? |
Yes
No (if No, go to #11) |
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2.
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Do you live in the U.S.? |
Yes (State)
No (Country)
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3.
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Have you had a medical procedure in a
hospital or surgical center in the U.S. within the past
year? |
Yes in USA
No, in another country
(If No, go to #20) |
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4.
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Please specify the procedure(s): |
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5.
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How satisfied were you with the quality
of the medical care you received at that time? |
Extremely satisfied
Quite Satisfied
Neutral
Not satisfied
Extremely unsatisfied |
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6.
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Do you agree with the statement: "When
Americans are sick, they want to be in the care of providers
they know and trust - even if they are not the best.
They will settle for inferior and more expensive treatment
in order to be home." |
Strongly Agree
Agree
No Opinion
Disagree
Strongly Disagree |
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7.
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Please add any additional comments you
wish on this topic: |
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8.
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Gender |
Male
Female |
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9.
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Age: |
under 18
18-24
25-34
35-44
45-54
55-64
65-74
over 74 |
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10.
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Do you currently have medical insurance? |
Yes
No |
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Finished - Go to end and click "Submit
Survey" |
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If you answered NO to Question 1, Start
Here. |
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11.
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Which country do you live in? |
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12.
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Have you had a medical procedure in a
hospital or surgical center within the past year? |
Yes, in my country of residence
Yes, in another country
No (If No, go to #20.) |
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13.
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Please specify the procedure(s) |
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14.
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How satisfied were you with the quality
of the medical care you received at that time? |
Extremely satisfied
Quite Satisfied
Neutral
Not satisfied
Extremely unsatisfied |
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15.
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Do you agree with the statement: "When
Americans are sick, they want to be in the care of providers
they know and trust - even if they are not the best.
They will settle for inferior and more expensive treatment
in order to be home." |
Strongly Agree
Agree
No Opinion
Disagree
Strongly Disagree |
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16.
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Please add any additional comments you
wish on this topic: |
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17.
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Gender |
Male
Female |
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18.
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Age: |
under 18
18-24
25-34
35-44
45-54
55-64
65-74
over 74 |
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19.
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Do you currently have medical insurance?
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Yes, government-provided
Yes, private
No |
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Finished - Go to end and click "Submit
Survey" |
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If you answered NO to Question 3 or 12,
Start Here |
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20.
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Was a medical procedure recommended for
you within the past year? |
Yes
No (If no, go to question #24) |
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21.
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How satisfied were you with the quality
of the medical examination and consultation you received
at that time? |
Extremely satisfied
Quite Satisfied
Neutral
Not satisfied
Extremely unsatisfied |
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22.
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Did you postpone it to a later date or
decide not to have it? |
Postponed it
Decided not to have it
Other [please explain]
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23.
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Please comment: |
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24.
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Do you agree with the statement: "When
Americans are sick, they want to be in the care of providers
they know and trust - even if they are not the best.
They will settle for inferior and more expensive treatment
in order to be home." |
Strongly Agree
Agree
No Opinion
Disagree
Strongly Disagree |
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25.
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Please add any additional comments you
wish on this topic: |
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26.
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Gender |
Male
Female |
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27.
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Age: |
under 18
18-24
25-34
35-44
45-54
55-64
65-74
over 74 |
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28.
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Do you currently have medical insurance?
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Yes, government-provided
Yes, private
No |
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Finished - Click Submit |
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