How would you describe your relationship with your primary care physician?

• Excellent
• Very good
• Good
• Fair
• Poor

Medical Professionals Seen in Last 12 Months

Generalists
• Primary Care Doctor (e.g., Family or Internal medicine, or General Practice)
• Nurse Practitioner/Physician Assistant
• Dentist/Oral Hygienist
• Physical Therapist/Sports Medicine
• Psychologist/Therapist

Specialists
• Allergist
• Cardiologist
• Dermatologist
• Diabetes Educator/Specialist
• Ear, Nose & Throat Specialist
• Endocrinologist
• Gastroenterologist
• Gynecologist
• Nephrologist
• Neurologist
• Oncologist
• Ophthalmologist
• Optometrist
• Orthopedist
• Pain Specialist
• Podiatrist
• Psychiatrist
• Pulmonologist
• Rheumatologist
• Surgeon
• Urologist

Complementary or Alternative Medicine
• Chiropractor
• Nutritionist


• Other medical professional
• None in the last 12 months

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?

• Doctor's office (private or group practice)
• 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+

Telemedicine is the use of technology to provide health care from a distance using a smartphone, tablet or computer. Would you ever consider using telemedicine or a virtual/online doctor visit, if this was an available option for you?

• Yes
• No

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

• Less than 6 months ago
• 6 months to less than 1 year
• Within last year
• 1 year to less than 2 years
• 2 years to less than 3 years
• 3 years to less than 5 years
• 5 years ago or more
• Never

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
• Bone density
• Cardiac/heart tests (e.g., EKG, stress test, etc.)
• Cholesterol
• Colonoscopy
• CT scan
• Diabetic Retinopathy
• Glaucoma
• HIV
• Kidney function
• Mammogram
• Pap smear
• Pregnancy
• Prostate exam
• Prostate Specific Antigen (PSA)
• STD/STI (e.g., chlamydia, genital herpes, HPV)
• Other medical testing

Vaccinations Received in Last 12 Months

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

Which of these pneumonia vaccinations you, yourself, have received in the last 12 months?

• Pneumovax 23
• Prevnar 13
• Other Pneumonia vaccine

What 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?

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 the following sources for healthcare information?

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

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

POINT OF CARE INFORMATION
• General magazines in a doctor’s office/waiting room
• Health-related magazines in a doctor’s office/waiting room
• Health-related television programs in a doctor’s office/waiting room
• Brochures, posters, other health education materials in a doctor’s office/waiting room
• Tablet computer in the exam room

POINT OF PURCHASE INFORMATION
• Ad/brochures/magazines in pharmacies
• In-store radio, TV or video
• Medication packaging/labels