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Q-1

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Q-2

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Q-3

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Q-4

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Q-5

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Q-7

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Q-8

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Q-9

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11

Q-11

1. Are you hospitalized or wheelchair bound?

1. Are you hospitalized or wheelchair bound?

Options :

Yes
No

2. Were you hospitalized 3 or more times over the past year?

2. Were you hospitalized 3 or more times over the past year?

Options :

Yes
No

3. Were you hospitalized anytime over the past 3 years?

3. Were you hospitalized anytime over the past 3 years?

Options :

Yes
No

4. Have you ever had an outpatient surgery?

4. Have you ever had an outpatient surgery?

Options :

Yes
No

5. Have you had an Emergency Room visit over the past 12 months?

5. Have you had an Emergency Room visit over the past 12 months?

Options :

Yes
No

6. Roughly, how many chronic conditions do you have currently?

6. Roughly, how many chronic conditions do you have currently?

Options :

0
1-3
3-5
5-8

7. Currently, how many specialist do you see for health related issues?

7. Currently, how many specialist do you see for health related issues?

Options :

0
1-3
3-5
5-8

8. Currently, how many prescriptions drugs are you taking?

8. Currently, how many prescriptions drugs are you taking?

Options :

0
1-3
3-5
5-8

9. Currently, how many prescriptions drugs are generic?

9. Currently, how many prescriptions drugs are generic?

Options :

0
1-3
3-5
5-8

10. Currently, how many times per year do you see your primary care doctor?

10. Currently, how many times do you see your primary care doctor?

Options :

0
1-3
3-5
5-8

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