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- Mental health disrupting daily life
Please indicate your level of agreement or disagreement with the following statement. In the past 12 months my mental health significantly disrupted my daily life. In the past 12 months my mental health significantly disrupted my daily life.
- Strongly disagree
- Somewhat disagree
- Neither agree nor disagree
- Somewhat agree
- Strongly agree
- Longest amount of time spent traveling to a healthcare visit (last 12 months)
In the past 12 months, what’s the longest amount of time it took for you or a family member to travel to a healthcare visit?
- Less than 15 minutes
- 15–30 minutes
- 31-60 minutes
- 61-90 minutes
- More than 90 minutes
- Not sure
- Longest amount of time spent waiting for a healthcare appointment (last 12 months)
In the past 12 months, what was the longest amount of time you or a family member had to wait between scheduling a healthcare appointment and the actual appointment date?
- Less than 1 week
- 1–4 weeks
- 5–8 weeks
- 9–12 weeks
- More than 12 weeks
- Not sure
- Medical Professional Listened to and Understood Patient Explanation
Thinking about your most recent care experience, to what extent did the medical professional listen to and understand your explanation of your health or condition?
- Completely
- Mostly
- Only partially
- Not at all
- Ease of understanding hospital or clinic bill
Thinking about the bill you have received for your most recent visit to the hospital or physician’s clinic, how easy or difficult was it to understand what you were being billed for?
- Very easy
- Somewhat easy
- Neither easy nor difficult
- Somewhat difficult
- Very difficult
- Reduced spending due to healthcare costs (last 3 months)
In the past three months, have you had to reduce spending on routine household expenses to pay for healthcare costs for you or a member of your household?
- Yes
- No
- Unable to schedule follow-up visit due to cost (last 12 months)
In the last 12 months, has there been a time that you were in need of a follow-up appointment but were unable to schedule it due to the cost?
- Yes
- No
- Not applicable (Did not need a follow-up appointment)
- Comfort in bringing up mental health issues with PCP
How comfortable or uncomfortable are you bringing up mental health issues (such as loneliness, depression, anxiety, anger, and social isolation) with a primary care provider?
- Very uncomfortable
- Somewhat uncomfortable
- Somewhat comfortable
- Very comfortable
- Factors preventing or delaying access to healthcare (last 12 months): Concern over what insurance will or will not cover
A medical professional is a licensed individual trained to diagnose, treat, and care for patients’ health needs, such as doctors, nurses, and physicians' assistants. In the past 12 months, have any of the following prevented or delayed you from accessing healthcare that you or a family member needed? Select all that apply. [Concern over what insurance will or will not cover]
- Yes, prevented access to healthcare
- Yes, delayed access to healthcare
- No, neither
- Factors preventing or delaying access to healthcare (last 12 months): Conflicting information from different providers
A medical professional is a licensed individual trained to diagnose, treat, and care for patients’ health needs, such as doctors, nurses, and physicians' assistants. In the past 12 months, have any of the following prevented or delayed you from accessing healthcare that you or a family member needed? Select all that apply. [Conflicting information from different providers]
- Yes, prevented access to healthcare
- Yes, delayed access to healthcare
- No, neither
- Does not apply