Your thoughts and ideas about keeping health appointments is important for us to know.

The Community Collaborative for Health Planning is a local group of organizations that wants to explore how to improve transportation related issues for patients and family members around their ability to keep their health related appointments. Please take a few minutes to complete this survey. It should take about 5 minutes to complete.

* 1. Please tell us about yourself:

* 2. How are you taking this survey?

* 3. Please tell us more about yourself and your beliefs/attitudes about health care:

  Yes No
Are you employed?
I take care of my health and my family's health; it's important to me.
I would get to all my health appointments if transportation was not a problem.
I only take care of my health when I am sick.
I would go to the Emergency Room even if it's not an emergency.

* 4. Tell us about scheduling health appointments:

  Yes No
I make my own appointment(s) with the health provider.
My family or support network makes appointment(s) for me.
My health provider's office makes appointment(s) for me and lets me know.
My health provider's office knows my transportation issues and helps me with them.
My health provider has convenient hours.
My health provider sends me reminders about appointments.
When making more than one health appointment, I schedule all in one day.
I have to schedule appointments to avoid drug side effects.

* 5. Tell us about your health care insurance coverage:

  Yes No
Do you have health insurance?
Does your insurance pay for transportation to and from appointments?
If health insurance pays for transportation, do you use it?

* 6. Please tell us about your personal transportation:

  Yes No
Do you drive your own vehicle?
Do family or friends drive you to and from health appointments?
Have you ever missed a health appointment because of no transportation?
Do you frequently miss health appointments and end up in the emergency room?

* 7. Please tell us about your use of public transportation (bus, taxicab, shuttle, health center):

  Yes No
Have you ever used public transportation?
Do you use public transportation all the time to get to and from health appointments?
If you use public transportation, are pick-up/drop off locations convenient?
Do you think the cost to ride is within your budget?

* 8. Check all the following you have used for transport to and from health appointments:

* 9. What things could our community do to help you keep health appointments:

* 10. What other thoughts or comments do you have about medical transportation?