Health insurance coverage survey questions + sample questionnaire template

Health Insurance Coverage Survey Template offers questions and examples on the quality of a respondent's current healthcare provider. This sample can be edited by the survey maker according to the required details about the health insurance coverage. Some of the question examples of this questionnaire are demographical such as "What is your age?", "What is your family's annual income?" or "What is your marital status?" et al.

Health insurance coverage survey questions + sample questionnaire template

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Please take a few minutes to fill out this survey on health insurance coverage. We value your feedback and your responses will be used to serve you better. Thank you for your input. Please provide us with the following information. 1. What is your gender? Male Female 4. What is the highest level of education you have attained? Primary school Some high school High school diploma or GED Some college 2 year college degree 4 year college degree Graduate level degree Other 5. What is your marital status? Married Widowed Divorced Separated Single never married 6. Are you disabled? Yes No 7. Please mark your annual gross income? 0 to $10,000 $10,001 to $25,000 $25,001 to $50,000 $50,001 to $100,000 $100,001 to $250,000 $250,001 + I prefer not to answer 8. Which of the following group of race best describes you? White Black or African American American Indian Asian Hispanic or Latino Two or more races 9. Which health coverage are you currently enrolled with? Medicaid Medicare Affordable Care Act Uninsured Private health insurance Other 10. How difficult is it for you to pay health insurance cost? Very difficult Somewhat difficult Neutral Somewhat easy Very easy 11. Do you have a child 26 years and below that you have been unable to include in your coverage? Yes No 12. Has any of your family members been dropped out of coverage after a diagnosis of some illness? Yes No 13. Has lack of health insurance cover made you consider one of the following? Skip a doctor’s appointment Cancel an appointment with a doctor Delay a doctor appointment Not purchase medicine N/A