1. Surveys
  2. 2004
  3. November
  4. W
  5. WS265SurveyMason
0%
 
Please answer these questions to the best of your ability.
Strongly Disagree Disagree Neutral Agree Strongly Agree Not sure
* It is important for Primary Care physicians to offer accommodating options for all patients.
* I have felt that my needs were not met, because options to describe my lifestyle were not included in the Patient Information Form that I was required to fill out.
* I have noticed that the common question of marital status offers three options: Married Single Divorced.
* I have felt alienated by these options, because they do not describe my lifestyle.
* I do not find the options of marital status to be limiting and I am not inhibited by these options.
* I do not think there should be options offered for individuals who are not married or single.
* I did not notice these options before, but I now realize that they do not provide an option for individuals who are in alternative relationships or who are in relationships, but not married.
* I think it is important to inform physicians of the alienation in their forms, so they can offer more options to be inclusive of all individuals.
* If an individual is not married, his/her relationships with other individuals do not need to be recognized.
* I know one or more individual(s) who would not be included in the options: Married Single Divorced.
* I do not know of any individuals who would not be included in the options: Married Single Divorced.
 
 
Would you be willing to participate in a discussion and/or ask your primary care physician about this question of 'Marital Status' on New Patient forms?
 
I would be willing to participate in a discussion and talk to my physician.
 
I would be willing to participate in a discussion, but unwilling to talk to my physician.
 
I would be willing to talk to my physician, but unwilling to participate in a discussion.
 
I would not be willing to participate in a discussion OR talk to my physician.
 
I am not sure
 
 
Do you think it is appropriate for Primary Care physicians and other health care providers to request information regarding your relationship status in their new patient forms?
 
Yes
 
No
 
Other
 
 
 
Which state do you live in?
 
 
What is your age?
   
 
 
What is your gender?
 
Male
 
Female
 
Other
 
 
 
What is your Relationship Status?
 
Married
 
Partnered with one or more individual(s)
 
Single
 
Divorced
 
Other
 
Please contact [email protected] or click here if you have any questions regarding this survey.