Healthcare Access Barriers Assessment Questionnaire Form
Please complete this questionnaire to help us better understand the barriers you may face in accessing healthcare services.
Age Group
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
How often do you experience difficulty affording healthcare services?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
How often does transportation limit your ability to access healthcare?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
How comfortable do you feel communicating with healthcare providers?
*
Not at all comfortable
1
2
3
4
Very comfortable
5
1 is Not at all comfortable, 5 is Very comfortable
Please rate your ability to schedule appointments at convenient times.
*
Very difficult
1
2
3
4
Very easy
5
1 is Very difficult, 5 is Very easy
How often does language or cultural difference create challenges in accessing care?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
How confident are you in knowing where and how to seek healthcare when needed?
*
Not at all confident
1
2
3
4
Very confident
5
1 is Not at all confident, 5 is Very confident
Do you have health insurance?
*
Yes
No
Prefer not to say
What is your primary type of healthcare provider?
*
Primary care physician
Community clinic
Urgent care center
Hospital emergency room
Other
Please describe any other barriers you face in accessing healthcare (optional).
Submit Assessment
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