Questionnaire: Healthcare profile and requirements

of the consumers

Quest. Code

Dear Sir/Madam Good Morning/Afternoon/Evening. I am from NexGen Market research Services Pvt
Ltd. We are a well-known market research agency. Time to time we conduct surveys on different
products and services. The idea to improve/enhance the existing services. We would like to request
you to answer some of the questions. Your views are important and it will be kept confidential and only
used for research purpose. Thanking you in advance.

Demographic profile of resident

Name of Respondent

Address

Area / Locality

Town / City Gender M F

Mobile Email Id

1 Your Self employed Service (Pvt Service (Govt Retired Others

occupation Job) Job)
1 2 3 4 ……………….

2 Average Upto Rs. Rs. 50,001 to Rs. 1,00,001 to Rs. 1,50,001 to More than Rs.
monthly 50,000 1,00,000 1,50,000 2,00,000 2,00,000
income 1 2 3 4 5

3 Are you a Permanent Resident of Yes No

Gurugram?
1 2

4 Type of Owned Rented Company/office provided

house 1 2 3

5 Family Age group Under 12 yrs 12 to18 yrs 18 to 25 yrs 25 to 40 yrs 40 to 55 yrs 55 & above
profile Male
Female
Total members
 Questionnaire: Healthcare profile and requirements
of the consumers

Access to the healthcare facilities (Requirement assessment of healthcare facilities)

6 How would you rate your Very Healthy Healthy Unhealthy Not Sure/ No idea
own personal health? 1 2 3 4

7 Which healthcare facility do you usually visit for? (Please mention Hospital/Clinic/Doctor Name)
In case of… Hospital Nursing home Clinic / Doctor Others
Medical …….
Emergency
Doctor …….
Consultations
Preventive Health Hospital/Nursing home Path Lab/ Diagnostic Clinic / Doctor Others
Check Investigation centre
…….

8 Which Specialty Hospital/Doctor

speciality do
you require General Medicine
most Urology
frequently?
(multiple Dermatology
possible)
Paediatrics
Cardiology
Neurology
OBST / Gynaecology
ENT
Gastroenterology
Pulmonology
Nephrology
Geriatrics (for senior citizens)
Diabetology & Endocrinology
Orthopaedics
Oncology
Ophthalmology
Dentist
Others ………………..

9 Do you have the health insurance? Yes No

1 2
 Questionnaire: Healthcare profile and requirements
of the consumers

10 What health services Sample Physiotherapy Nutrition & Pharmacy Others

do you require Collection Dietetics
serviced to your home 1 2 3 4 ……
(home care services)?

11 What health facility would you like to have in

your neighbourhood?

Awareness of healthcare facilities in the region

12 What are the best hospitals/doctors in your

neighbourhood? (Please name top 2)

13 Are you aware of Narayana Health? Yes No

General questions related to healthcare facilities

14 How far you visit to avail the healthcare facility? (Distance in kms)

15 Do you go outside the locality / city to avail the healthcare facility? Yes No

16 If yes, what was the reason?

17 Which Number would you call in case of a Medical Emergency?

18 If Narayana Health open a Health Centre which health care

services do you need in that centre & which area is required?

19 What are your expectations from Narayana Health in this region?

Thank you so much