14. one of the following clinics do you go to when you see your primary doctor or nurse? 1 [CLINIC 1] 3 [CLINIC 2] 4 [CLINIC 3] 5 [CLINIC 4] 6 [CLINIC 5] 7 Another clinic Please 15. In the last 12 months, how many did you visit your primary doctor or nurse to get care for yourself? None If None, go to #29 on page 6 1 time 2 3 4 5 to 9 10 or more times 16. In the last 12 months, did your primary doctor or nurse suggest that you see a specialist for a health problem? 1 Yes 2 No If No, go to #18 17. In the last 12 months, how often did your primary doctor or nurse seem informed and up-to-date about the care you got from specialists? 1 Never 2 Sometimes 3 Usually 4 Always 18. In the last 12 months, did you and your primary doctor or nurse talk about specific things you could do to prevent illness? 1 Yes 2 No 19. In the last 12 months, did you want your primary doctor or nurse’s help in making changes in your habits or lifestyle to prevent illness? 1 Yes 2 No 20. In the last 12 months, did your primary doctor or nurse encourage you to talk about your health concerns, including those that might be embarrassing? 1 Yes 2 No 21. In the last 12 months, did you and your primary doctor or nurse talk about how to maintain a healthy diet and healthy eating habits? 1 Yes 2 No 22. In the last 12 months, did you and your primary doctor or nurse talk about the exercise or physical activity you get? 1 Yes 2 No 23. In the last 12 months, did you and your primary doctor or nurse talk about things in your life that worry you or cause you stress? 1 Yes 2 No
Making Decisions About Your Care 47. Choices for your treatment or health care can include choices about medicine, surgery, or other treatment. In the last 12 months, did a doctor or other health professional recommend a treatment for a health problem that was bothering you? 1 Yes 2 No 48. In the last 12 months, did a doctor or health professional tell you there was more than one choice for your treatment or health care? 1 Yes 2 No If No, go to #51 49. In the last 12 months, did a doctor or other health professional talk with you about the pros and cons of each choice for your treatment or health care? 1 Definitely yes 2 Somewhat yes 3 Somewhat no 4 Definitely no 50. In the last 12 months, when there was more than one choice for your treatment or health care, did a doctor or other health professional ask which choice you thought was best for you? 1 Definitely yes 2 Somewhat yes 3 Somewhat no 4 Definitely no Clerks and Receptionists at Your [NAME OF PROVIDER] Clinic 51. In the last 12 months, how often were clerks and receptionists at your [NAME OF PROVIDER] clinic as helpful as you thought they should be? 1 Never 2 Sometimes 3 Usually 4 Always 52. In the last 12 months, how often did clerks and receptionists at your [NAME OF PROVIDER] clinic treat you with courtesy and respect? 1 Never 2 Sometimes 3 Usually 4 Always Prescriptions 53. In the last 12 months, did you need any new prescription medicine or need to refill a prescription? 1 Yes 2 No If No, go to #56 54. In the last 12 months, was it easy to get prescription medicine you needed through your [NAME OF PROVIDER] clinic? 1 Definitely yes 2 Somewhat yes 3 Somewhat no 4 Definitely no
55. In the last 12 months, how often did you get the prescription medicine you needed through your [NAME OF PROVIDER] clinic? 1 Never 2 Sometimes 3 Usually 4 Always Overall Rating Of Clinic 56. For this next question, please think about the [NAME OF PROVIDER] clinic you visited most often in the last 12 months. Using any number from 0 to 10 where 0 is the worst clinic possible and 10 is the best clinic possible, what number would you use to rate the clinic? 0 Worst possible clinic 1 2 3 4 5 6 7 8 9 10 Best possible clinic Discrimination 57. In the last 12 months, have you ever felt that a health professional you saw judged you unfairly or treated you with disrespect for any reason? 1 Yes 2 No If No, go to #60 58. In the last 12 months, did you feel that a health professional you saw judged you unfairly or treated you with disrespect because of your tribal affiliation? 1 Yes 2 No 59. Blood quantum level refers to the level of tribal blood required for membership in an Indian tribe. In the last 12 months, did you feel that a health professional you saw judged you unfairly or treated you with disrespect because of your blood quantum level? 1 Yes 2 No 3 I’m not sure Look for Information 60. In the last 12 months, did you look for information in written materials or on the Internet about how to get care from a [NAME OF PROVIDER] clinic or hospital? 1 Yes 2 No If No, go to #62 61. In the last 12 months, how did the written materials or the Internet provide the information you wanted on how to get care from a [NAME OF PROVIDER] clinic or hospital? 1 Never 2 Sometimes 3 Usually 4 Always
62. Do you know if [NAME OF PROVIDER] has a website? 1 Yes 2 No If No, go to #65 63. In the last 12 months, did you visit the [NAME OF PROVIDER] website to get information or help about the hospital or clinics? 1 Yes 2 No If No, go to #65 64. In the last 12 months, how often did the [NAME OF PROVIDER] website provide the information or help you wanted about the hospitals or clinics? 1 Never 2 Sometimes 3 Usually 4 Always About You are only a few questions left. 65. In general, how you rate your overall health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor 66. In general, how would you rate your overall mental or emotional health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor 67. In the past 12 months, have you seen a doctor or other health professional three or more times for the same condition or problem? 1 Yes 2 No If No, go to #69 68. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy. 1 Yes 2 No 69. Do you now need or take medicine prescribed by a doctor? Do not include birth control. 1 Yes 2 No If No, go to #71 70. Is this to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause. 1 Yes 2 No 71. What is your age? 1 18 to 24 2 25 to 34 3 35 to 44 4 45 to 54 5 55 to 64 6 65 to 74 7 75 or 72. Are you male or female? 1 Male 2 Female
74. What is your race? Please mark one or more. 1 American Indian or Native Please print your tribal affiliation: 2 White 3 Asian 4 Black or African-American 5 Native Hawaiian or Pacific Islander 6 Other Please print: 75. What language do you mainly speak at home? 1 English 2 [NATIVE LANGUAGE] 8 Some other language Please print: 76. Did someone help you complete this survey? 1 Yes 2 No you. Please return the completed survey in the postage-paid envelope. 77. How did that person help you? Mark one or more. 1 Read the questions to me 2 down the answers I gave 3 Answered the questions for me 4 Translated the questions into my language 5 Helped in some other way Thank you. Please return the completed survey in the postage-paid envelope.