Survey on Community Health Services
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1. Default Section
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1
. Clinic Profile
Clinic Profile
Name of Doctor
Name of Clinic
Address
Contact Number
Email Address
% of Chronic Patients
Medisave/CDMP participant (Y/N)
2
. Computerisation usage in the Clinic
Computerisation usage in the Clinic
Registration
Clinical notes
Bill/Invoice
Prescription
Medication labels
Medical chit
Inventory
Report generation
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3
. From the list below, tick the type of services that would complement your medical practice and 1) indicate the price range that your patients would be willing to pay; and 2) the referral frequency.
<$10
$10-<$15
$15-<$20
$20-<$25
$25-<$30
$30& >
1-5 times/yr
6-10 times/yr
>10 times/yr
Diabetic Retinal Photography (DRP)
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From the list below, tick the type of services that would complement your medical practice and 1) indicate the price range that your patients would be willing to pay; and 2) the referral frequency. Diabetic Retinal Photography (DRP) <$10
Diabetic Retinal Photography (DRP) $10-<$15
Diabetic Retinal Photography (DRP) $15-<$20
Diabetic Retinal Photography (DRP) $20-<$25
Diabetic Retinal Photography (DRP) $25-<$30
Diabetic Retinal Photography (DRP) $30& >
Diabetic Retinal Photography (DRP) 1-5 times/yr
Diabetic Retinal Photography (DRP) 6-10 times/yr
Diabetic Retinal Photography (DRP) >10 times/yr
Diabetic Foot Screening (DFS)
Diabetic Foot Screening (DFS) <$10
Diabetic Foot Screening (DFS) $10-<$15
Diabetic Foot Screening (DFS) $15-<$20
Diabetic Foot Screening (DFS) $20-<$25
Diabetic Foot Screening (DFS) $25-<$30
Diabetic Foot Screening (DFS) $30& >
Diabetic Foot Screening (DFS) 1-5 times/yr
Diabetic Foot Screening (DFS) 6-10 times/yr
Diabetic Foot Screening (DFS) >10 times/yr
Nurse Educator/Care Management
Nurse Educator/Care Management <$10
Nurse Educator/Care Management $10-<$15
Nurse Educator/Care Management $15-<$20
Nurse Educator/Care Management $20-<$25
Nurse Educator/Care Management $25-<$30
Nurse Educator/Care Management $30& >
Nurse Educator/Care Management 1-5 times/yr
Nurse Educator/Care Management 6-10 times/yr
Nurse Educator/Care Management >10 times/yr
Dietitian Counselling
Dietitian Counselling <$10
Dietitian Counselling $10-<$15
Dietitian Counselling $15-<$20
Dietitian Counselling $20-<$25
Dietitian Counselling $25-<$30
Dietitian Counselling $30& >
Dietitian Counselling 1-5 times/yr
Dietitian Counselling 6-10 times/yr
Dietitian Counselling >10 times/yr
Physiotherapy
Physiotherapy <$10
Physiotherapy $10-<$15
Physiotherapy $15-<$20
Physiotherapy $20-<$25
Physiotherapy $25-<$30
Physiotherapy $30& >
Physiotherapy 1-5 times/yr
Physiotherapy 6-10 times/yr
Physiotherapy >10 times/yr
Podiatry
Podiatry <$10
Podiatry $10-<$15
Podiatry $15-<$20
Podiatry $20-<$25
Podiatry $25-<$30
Podiatry $30& >
Podiatry 1-5 times/yr
Podiatry 6-10 times/yr
Podiatry >10 times/yr
Lab Investigations (price not applicable)
Lab Investigations (price not applicable) <$10
Lab Investigations (price not applicable) $10-<$15
Lab Investigations (price not applicable) $15-<$20
Lab Investigations (price not applicable) $20-<$25
Lab Investigations (price not applicable) $25-<$30
Lab Investigations (price not applicable) $30& >
Lab Investigations (price not applicable) 1-5 times/yr
Lab Investigations (price not applicable) 6-10 times/yr
Lab Investigations (price not applicable) >10 times/yr
Radiology (price not applicable)
Radiology (price not applicable) <$10
Radiology (price not applicable) $10-<$15
Radiology (price not applicable) $15-<$20
Radiology (price not applicable) $20-<$25
Radiology (price not applicable) $25-<$30
Radiology (price not applicable) $30& >
Radiology (price not applicable) 1-5 times/yr
Radiology (price not applicable) 6-10 times/yr
Radiology (price not applicable) >10 times/yr
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4
. Where do you currently refer your patients to for the above-mentioned complementary (nursing, allied health and support) services?
Nursing Services (DRP,DFS etc)
Allied Health Services (dietitian etc)
Laboratory Investigations (blood tests)
X-ray Services
Public Hospitals
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Where do you currently refer your patients to for the above-mentioned complementary (nursing, allied health and support) services? Public Hospitals Nursing Services (DRP,DFS etc)
Public Hospitals Allied Health Services (dietitian etc)
Public Hospitals Laboratory Investigations (blood tests)
Public Hospitals X-ray Services
Polyclinics
Polyclinics Nursing Services (DRP,DFS etc)
Polyclinics Allied Health Services (dietitian etc)
Polyclinics Laboratory Investigations (blood tests)
Polyclinics X-ray Services
Private Providers
Private Providers Nursing Services (DRP,DFS etc)
Private Providers Allied Health Services (dietitian etc)
Private Providers Laboratory Investigations (blood tests)
Private Providers X-ray Services
Others - e.g. SATA, DSS
Others - e.g. SATA, DSS Nursing Services (DRP,DFS etc)
Others - e.g. SATA, DSS Allied Health Services (dietitian etc)
Others - e.g. SATA, DSS Laboratory Investigations (blood tests)
Others - e.g. SATA, DSS X-ray Services
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5
. What are the reasons for referring patients to the said institutions?
What are the reasons for referring patients to the said institutions?
Public Hospitals
Polyclinics
Private Hospitals
Others - e.g. SATA, DSS
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6
. Rank the following factors in the order of importance (1-most important; 7-least important) in influencing your decision to refer patients for complementary services. Do not repeat the ranking.
1
2
3
4
5
6
7
Distance of service provider from your clinic
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Rank the following factors in the order of importance (1-most important; 7-least important) in influencing your decision to refer patients for complementary services. Do not repeat the ranking. Distance of service provider from your clinic 1
Distance of service provider from your clinic 2
Distance of service provider from your clinic 3
Distance of service provider from your clinic 4
Distance of service provider from your clinic 5
Distance of service provider from your clinic 6
Distance of service provider from your clinic 7
Range of services offered
Range of services offered 1
Range of services offered 2
Range of services offered 3
Range of services offered 4
Range of services offered 5
Range of services offered 6
Range of services offered 7
Cost of services
Cost of services 1
Cost of services 2
Cost of services 3
Cost of services 4
Cost of services 5
Cost of services 6
Cost of services 7
Reputation of service provider
Reputation of service provider 1
Reputation of service provider 2
Reputation of service provider 3
Reputation of service provider 4
Reputation of service provider 5
Reputation of service provider 6
Reputation of service provider 7
Turnaround time for results
Turnaround time for results 1
Turnaround time for results 2
Turnaround time for results 3
Turnaround time for results 4
Turnaround time for results 5
Turnaround time for results 6
Turnaround time for results 7
Patient’s preference
Patient’s preference 1
Patient’s preference 2
Patient’s preference 3
Patient’s preference 4
Patient’s preference 5
Patient’s preference 6
Patient’s preference 7
Ease of referral
Ease of referral 1
Ease of referral 2
Ease of referral 3
Ease of referral 4
Ease of referral 5
Ease of referral 6
Ease of referral 7
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7
. Rank your preference (1 - most preferred; 6 - least preferred) for the location of the service provider. Do not repeat the ranking.
1
2
3
4
5
6
Stand-alone building
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Rank your preference (1 - most preferred; 6 - least preferred) for the location of the service provider. Do not repeat the ranking. Stand-alone building 1
Stand-alone building 2
Stand-alone building 3
Stand-alone building 4
Stand-alone building 5
Stand-alone building 6
Shopping centre
Shopping centre 1
Shopping centre 2
Shopping centre 3
Shopping centre 4
Shopping centre 5
Shopping centre 6
Community centre
Community centre 1
Community centre 2
Community centre 3
Community centre 4
Community centre 5
Community centre 6
Public hospital
Public hospital 1
Public hospital 2
Public hospital 3
Public hospital 4
Public hospital 5
Public hospital 6
Private hospital
Private hospital 1
Private hospital 2
Private hospital 3
Private hospital 4
Private hospital 5
Private hospital 6
Polyclinic
Polyclinic 1
Polyclinic 2
Polyclinic 3
Polyclinic 4
Polyclinic 5
Polyclinic 6
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8
. What is your preferred mode of billing?
What is your preferred mode of billing?
Billed to your clinic
Billed to our patient who pays at the service point
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