Overall, how would you describe your relationship with your primary care physician?

• Excellent
• Very good
• Good
• Fair
• Poor

Medical Professionals Seen in Last 12 Months

• Acupuncture/Acupressure Practitioner
• Allergist
• Cardiologist
• Chiropractor
• Dentist/Oral Hygienist
• Dermatologist
• Diabetes Educator/Specialist
• Ear, Nose & Throat Specialist
• Endocrinologist
• Gastroenterologist
• Gynecologist
• Hematologist
• Neurologist
• Nurse Practitioner/Physician Assistant
• Nutritionist
• Obstetrician
• Oncologist
• Ophthalmologist
• Optometrist
• Orthopedist
• Pain Specialist
• Periodontist
• Physical Therapist/Sports Medicine
• Podiatrist
• Primary Care Doctor (e.g., Family or Internal medicine, or General Practice)
• Psychiatrist
• Psychologist/Therapist
• Pulmonologist
• Rheumatologist
• Surgeon – Cosmetic/Plastic
• Surgeon – Other
• Urologist
• Other medical professional

How many times have you seen each of these types of medical professionals in the last 12 months?

• Any
• 1
• 2-3
• 4-6
• 7+

In the last 12 months, where have you received any kind of medical or health-related services?

• Emergency room (ER)
• Hospital
• Infusion Center
• Outpatient or Specialized care clinic
• Retail health or In-store clinic
• Surgery Center
• Telemedicine/Virtual or Online Doctor Visit (using a smartphone, tablet or computer)
• Urgent or Immediate care center (“walk-in” clinic)
• Other type of health facility

How many times in the last 12 months have you received medical or health-related services from each of these types of healthcare providers?

• Any
• 1
• 2-3
• 4-6
• 7+

Medical Professionals Taken A Child To See in Last 12 Months

• Allergist
• Dentist
• Ear, Nose & Throat specialist
• Nurse Practitioner/Physician’s Assistant
• Pediatrician
• Primary Care Doctor (e.g., Family or Internal medicine, or General Practice)
• Psychiatrist
• Other medical professional

Most Recent Annual Physical

• 6 months ago or less
• +6 months to 1 year
• Within last year
• +1 year to 2 years
• +2 years to 3 years
• +3 years to 5 years
• More than 5 years ago
• Never been

Importance of Regular Medical Check-Ups

• Extremely important (10)
• Mostly important (8-9)
• Somewhat important (6-7)
• Slightly important (2-5)
• Not at all important (1)

Medical Tests in Last 12 Months

• Allergy (skin or blood test)
• Blood glucose
• Blood pressure
• Bone density
• Cholesterol
• Colonoscopy
• Diabetic Retinopathy
• Eye exam
• Glaucoma
• HIV
• Kidney function
• Mammogram
• Pap smear
• Pregnancy
• Prostate exam
• Prostate Specific Antigen (PSA)
• STD
• Other medical testing

In the last 12 months, have you used or gotten any information from in-store blood pressure or heart rate monitor machine?

• Yes, used
• Yes, got information
• Neither

Vaccinations Received in Last 12 Months

• Flu
• Hepatitis
• HPV
• Meningitis
• Pneumonia
• Shingles
• Whooping Cough
• Other

HPV Vaccinations Received in Last 12 Months

• Cervarix
• Gardasil
• Other HPV vaccine

Which of these actions did you take after seeing any type of medical professional in the last 12 months?

• PRESCRIPTIONS
• Received a prescription for a new drug
• Filled a prescription
• Switched to a different prescription
• Took medication as prescribed


• ONLINE
• Conducted an online search about a condition
• Conducted an online search about a drug or treatment options
• Looked up cost of medication or insurance coverage before filling a prescription
• Looked into alternative treatments after receiving prescription
• Visited a pharmaceutical company or drug brand website
• Visited a social media site related to a condition or prescribed treatment


• MEDICAL OR PERSONAL HEALTH
• Went to see a specialist
• Went for x-rays, medical tests, or vaccines
• Made an effort to eat healthier or exercise more

How much do you agree or disagree with each of the following statements?

Any Agree, Agree a lot, Agree a little, Neither agree or disagree, Disagree a little, Disagree a lot, Any Disagree

• I am willing to ask my doctor for a prescription medication or drug sample that I have seen or heard advertised
• I often discuss new prescription medicines with my doctor
• Normally, I only use drug brands that are recommended by my physician
• I always do what my doctor tells me to do
• I research treatment options on my own and then ask my doctor about them
• I do not seek help from doctors or nurses unless I am very sick or injured

How much do you value each of the following as sources for healthcare information?

Very much, Somewhat, Not very much, Not at all

• HEALTHCARE PROVIDERS
• Alternative/holistic medical practitioners
• Doctor
• Nurse/Physician Assistant


• DOCTOR’S OFFICE OR WAITING ROOM
• Brochures/pamphlets in a healthcare professional’s office
• General magazines in a healthcare professional’s office
• Health-related magazines in a healthcare professional’s office
• Health-related television programming in a healthcare professional’s office
• Posters/wallboards in a healthcare professional’s office


• EXAM ROOM
• Brochures, wallboards or other information in a healthcare professional’s exam room
• Tablet computer in a healthcare professional’s exam room

How much do you value each of the following as sources for healthcare information?

Very much, Somewhat, Not very much, Not at all

• Ad/brochures in grocery stores
• Ad/brochures/magazines in pharmacies
• In-store radio, TV or video
• Medication packaging/labels
• Pharmacists