Women consumers - Demographic questionnaire

Attachment 5

Consumer Demographic Questionnaire

Focus Group Reference #_________________________

Thank you for taking the time to complete this short questionnaire. Your participation is very important.

1. Which of the following categories best describes your age?

• 18-24

• 25-34

• 35-44

• 45 or older

2. Have you given birth to a baby within the past 12 months?

• Yes

• No

2. How many children do you have? ________

What is/are the ages of the child/children?

Child 1 ___________ Child 4___________

Child 2 ___________ Child 5____________

Child 3___________

2. [For certain groups] During your most recent pregnancy, did you get routine prenatal checkups?

• Yes

• No

Reason(s) you did not get prenatal checkups (Check all that apply)

• Unable to pay the bill or copayments (i.e., not enough money)

• No insurance

• Problems with access (i.e., no transportation to get to a health care facility)

• Did not know a doctor

• Lack of support from your significant other

• Opinions of your friends or family

• Other (Please explain)_________________________

2. What type of medical insurance coverage best describes what you currently have?

• Private Insurance Plan through employer or self pay

• Medicaid

• Peachcare (SCHIP)

• Other Public Program

• Military/TRICARE

• Not Applicable (Uninsured)

2. [For certain groups] Did you see a provider (e.g. doctor, midwife) for a preconception appointment prior to becoming pregnant? If so, how long before you became pregnant did you see a provider:_____________

OR

Do you intend to see a provider (e.g. doctor, midwife) for a preconception appointment before you become pregnant? If so, how long before you become pregnant would you see a provider: _________________

2. In your opinion, what was the most important piece of information discussed today?

__________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Are you Hispanic or Latino?

• Yes

• No

2. Which of the following categories best describes your race? (check all that apply)

• American Indian or Alaskan Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

2. What is your current occupational job status?

• Full-time employed

• Part-time employed

• Not-working/Unemployed

• Housewife/Homemaker/Stay at home mom

• Full-time student

• Other (Please Describe) _________________________

2. What is your highest level of education?

• Some School

• High School Graduate

• Some College

• 2 Year College

• 4Year College

• Postgraduate

• Other____________________________

Thank you for completing the questionnaire.

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