Healthcare Expenses Template

NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.

Question Title

* 1. Do you currently have health insurance, or not?

Yes, I do

No, I do not

Question Title

* 2. Who pays for your health insurance? (Check all that apply)

Current employer

State government

Former employer

Local government

National government

Self funded

Other (please specify)

Question Title

* 3. How much money, in U.S. dollars, do you spend on health insurance premiums, deductibles, copays, and co-insurance fees in a typical month?

Premiums

Deductibles

Copays

Co-insurance fees

Question Title

* 4. How much money, in U.S. dollars, do you spend on healthcare in a typical month? (Count all healthcare-related costs, including health insurance premiums, deductibles, copays, co-insurance fees, and any other out-of-pocket expenses for medical, dental, or vision services and medications.)

Question Title

* 5. In the last 12 months, has a lack of money kept you from going to the doctor, or not?

Yes, it has

No, it has not