1. Introduction Section

Plaza Research Houston is conducting a discussion with consumers 25 years and older on Healthcare Decisions. The discussion will take place on Monday, March 6th, 2017 throughout the day. If you qualify and participate, you will receive $150 for 2.25-hours of your time, which includes a mandatory homework assignment. 
 
Please answer the questions below. If you look like a match, we will contact you by telephone.  

**Due to the large response to our surveys, we are only able to contact those that look like a match. Please continue to answer future studies, as you may be a match to those.

* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match. 

* 2. Alternate Contact number

* 3. What is your age? Whole number, no ranges or words

* 5. What role do you play in making decisions around health care for yourself and others in your household?

* 6. Which of the following types of doctors have you seen or had personally in the past year?

  My regular doctor I have seen before A new doctor I have not seen before I have not seen
Primary Care Physician
Gastroenterology – for digestive health
Orthopedic – for joint or musculoskeletal health
Oncology – for a cancer diagnosis/treatment
Cardiology – for heart health
Dermatology – for skin health
Ophthalmology – for eye health

* 7. Which health care system or physician group does the doctor you’ve seen in the past year belong to?

  Memorial Hermann UT Physicians UTMB Faculty Group Practice Houston methodist Specialty Physicain Group CHI St. Luke's Health network Tenet Healthcare Corp’s Physician Performance Network Kelsey-Seybold Clinic MD Anderson Cancer Network and MD Physician Network Not affiliated with a physician group None of the above I have not seen
Primary Care Physician
Gastroenterology – for digestive health
Orthopedic – for joint or musculoskeletal health
Oncology – for a cancer diagnosis/treatment
Cardiology – for heart health
Dermatology – for skin health
Ophthalmology – for eye health

* 8. Which if any of the following have you been diagnosed with?

* 9. If yes to any type of cancer, when were you first diagnosed? Month and year (MM/YY)

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