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Doctor Experience Survey
A survey to collaborate a list of helpful doctors.
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* Indicates required question
What is your age?
*
Under 18 years old
18-24 years old
25-34 years old
35-44 years old
45-54 years old
Over 55 years old
I prefer not to say
What is your gender?
*
Female
Male
Nonbinary
Transgender Male
Transgender Female
I prefer not to say
What is your ethnicity?
*
White/Caucasian
Hispanic/Latino
Black/African American
Native American/American Indian
Asian/Pacific Islander
I prefer not to say
Other:
What Chronic illness or illnesses have you been diagnosed with?
*
Your answer
Have you had a positive experience with any of your doctors?
*
Yes
No
Does this provider accept insurance?
*
Yes
No
I don't know
What type of insurance does this provider accept?
*
Private
Medicare
Medicaid
I don't know
Not Applicable
Required
What is this doctor's specialty?
*
Your answer
What is the name of the doctor(s)
*
Your answer
Please provide the address, phone number and website of the doctor or doctors.
*
Your answer
Have you had a positive experience with any specific medical groups or clinics?
*
Yes
No
What is the name of this clinic or these clinics, and what is the address of the clinic practice?
*
Your answer
Would you recommend this clinic to a friend or someone who is struggling with the same illness? If so, give a brief summary why?
*
Your answer
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