Health Insurance Coverage Survey 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.


 
 
 
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

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