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• UNLE S I HE'W E NDIC TEl 'LEASE CHECK THE APPROPRIATE SPACE OMNI <br /> 21. If the answer to !20 was "private insurance", does your insurance pay: <br /> 1) All inpatient charges <br /> 2) 8O% of inpatient charges <br /> 3) All outpatient charges <br /> 4) 80% of outpatient charges <br /> 5) HMO, prepaid insurance <br /> 6) Other (Phase specify) <br /> 22. Please RANK the following health cart factors in terms of their importance <br /> to you. For example: place 1 by the item most important and 2 by the item <br /> next in Importance, and so on. <br /> a) Attractive, modern facilities <br /> b) Convenient location <br /> c) Quality of care <br /> d) Friendly staff <br /> e) Other (Please specify) <br /> 23. Does anyone in your home have any of the following health problems? <br /> TOTAL NUMBER PERSONS TOTAL NUMBER UNDER <br /> IN HOUSEHOLD WITH DOCTOR'S CARE <br /> PROBLEM <br /> Respiratory (includes <br /> bronchitis, pnuemonia, colds, <br /> flu) 1) <br /> Circulatory (includes <br /> vascular, heart condition) 2) <br /> Digestive problems 3) <br /> Urinary tract problems 4) <br /> Metabolic (includes pancreas, <br /> liver, spleen, gall bladder) 5) <br /> Headaches 6) _ <br /> Trouble seeing <br /> (corrected with glasses) 7) _ <br /> Hearing problems <br /> (corrected with hearing aid) 8) <br /> Allergies 9) - - <br /> Back/neck trouble 10) <br /> Arthritis 11) <br />