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UNL aS OTHERWISE INO ATED, -PLEASE CHECK THE APPROPRIATE SSACE(S) ) <br /> 16. If the answer to 015 was yes, or if you have not needed care, please <br /> skip to Question #17. If the answer to #15 was no, please indicate <br /> the reason(s) for your dissatisfaction with a checkmark below. <br /> 1) No personal physician <br /> 2) Too far to drive <br /> 3) Treatment by medical staff <br /> 4) Costs too mucn <br /> 5) Have to wait too long for <br /> an appointment <br /> 6) Other (Please specify) <br /> 17. How many miles do you now travel to get healthcare services? <br /> 1) 0 - 5 miles <br /> 2) 6 - 10 miles <br /> 3) 11 - 15 miles <br /> 4) 16 - 20 miles <br /> 5) More than 20 miles <br /> 18. If you needed to be admitted to a hospital, or if you have been admitted <br /> to a hospital in the past year. who decides which hospita to use? <br /> 1) Self <br /> 2) Doctor's decision <br /> 3) Joint decision <br /> 4) Emergency transportation <br /> (Example: Ambulance) <br /> 5) Other (Please specify) <br /> 19. If you receive treatment at a hospital emergency room, is it because: <br /> 1) No other 24 hour service <br /> available <br /> 2) No personal physician <br /> 3) Personal physician on hospital <br /> staff <br /> 41 Transported by emergency <br /> vehicle <br /> 5) No available clinic for <br /> routine care <br /> 6) Other (Please specify) <br /> 20. Do you have health insurance under one of the following? <br /> 1) Medicare <br /> 2) Medicaid <br /> 3) Private insurance <br /> 4) None <br />