.

Health Care Survey

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

Secured
Survio
Create a survey
Health Care Survey
1

A. Sex

Select one or more answers
Create a survey
Health Care Survey
2

B. Reason for non-participation

I would like to start with a few general questions about you and your household.
Create a survey
Health Care Survey
3

I. Name of participants

Select one or more answers
Create a survey
Health Care Survey
4

II. Gender

Select one or more answers
Create a survey
Health Care Survey
5

III. In which year you were born

Select one or more answers
Create a survey
Health Care Survey
6

IV. Would you describe the area in which you live as being a city, town, village, or countryside ?

Select one or more answers
Create a survey
Health Care Survey
7

V. How many people are living in tour, including you ?

Select one or more answers
Create a survey
Health Care Survey
8

Vl. Are there children under age of 12 in your household?

Select one or more answers
Create a survey
Health Care Survey
Create a survey