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Understanding the Patient Experience and Bias in Healthcare
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1.
What is your age range?
(Required.)
18-24
25-34
35-44
45-54
55-64
65+
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2.
What gender do you identify as?
(Required.)
Male
Female
Transgender
Non-binary
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3.
What is your ethnicity?
(Required.)
White or Caucasian
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Another race
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4.
Have you ever felt you were treated differently by a medical professional because of one or more of these factors?
(Required.)
Race
Ethnicity
Being Female
Identifying as LGBTQIA
Body Size
Age
Other (please specify)
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5.
Have you ever felt you were not listened to by a current or past medical professional?
(Required.)
Yes
No
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6.
Have you ever changed doctors because you did not like the way a medical professional treated you?
(Required.)
Yes
No
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7.
If you had a choice of equally competent doctors, which factor would be more important in selecting your physician?
(Required.)
Same gender as me
Same race/ethnicity as me
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8.
What would your primary reason be for your choice in question 7?
(Required.)
I believe they would understand me better.
I believe they would listen better.
I would be more comfortable with them.
I want to support people like me.
Other (please specify)
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9.
Who do you feel is most likely to practice empathy when you are undergoing medical treatment?
(Required.)
Physician
Physician Assistant
Nurse Practitioner
Nurse
Other (please specify)
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10.
What percentage of the time do you feel your current doctor listens to you?
(Required.)
0
100
Clear
11.
Please explain why feel your doctor does not listen to you.
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12.
What percentage of the time do you follow your doctor's treatment instructions?
(Required.)
0
100
Clear
13.
Please explain why you do not follow your doctor's treatment instructions.
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14.
What percentage of the time do you feel vulnerable when you are at a medical appointment/procedure?
(Required.)
0
100
Clear
15.
Please explain what makes you feel vulnerable during a medical appointment/procedure.
16.
How would you rate the following factors in your selection of a medical professional?
Not important
Somewhat important
Important
Very important
Their reputation/knowledge
Not important
Somewhat important
Important
Very important
Recommendation from family/friend
Not important
Somewhat important
Important
Very important
How they listen to me during appointments
Not important
Somewhat important
Important
Very important
How friendly they are
Not important
Somewhat important
Important
Very important
How they explain things to me
Not important
Somewhat important
Important
Very important
Other (please specify)
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17.
Which of the following best describes your current relationship status?
(Required.)
Married
Widowed
Divorced
Separated
In a domestic partnership or civil union
Single, but cohabiting with a significant other
Single, never married
Prefer not to answer
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18.
What is the highest level of education you have completed?
(Required.)
Graduated from high school
2 years of college
Graduated from college
Completed graduate school
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19.
What is your total household income?
(Required.)
Less than $20,000
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 or More
20.
Would you share a story about when you felt dismissed by a medical professional? Please do not include personal information or names.