Name: ___________________________________________ Place:_________________

Qualification: _____________________________ Years in Practice:___________________

1. What are the economic status/Payment modes of patients visiting? (Tick more than 1 if
applicable)
1 2 3
Cash Payments Corporate Govt. Health Schemes

2. What is the ratio of patients having Health Insurance to that of those who don’t?
Health Insured : Non Health Insured
:

3. What are the most common problems in the patients: (Please tick more than one if applicable?)
1 Urology
2 Gastroenterology
3 Cardiology + Paediatrics Cardiology
4 Oncology
5 Orthopaedics (Knee / Hip Transplants)
6 Neurology (Brain & spine Surgery)
7 Minimal Access Surgery (Lasers & Transplants)

5. Do you think there is a need for a Tertiary Care Hospital here?

Yes No Don’t Know

6. If yes, then which speciality Hospital would you suggest? (Please rank them on priority, 1 being
most required)
Urology
Gastroenterology
Cardiology + Paediatrics Cardiology
Oncology
Orthopaedics (Knee / Hip Transplants)
Neurology (Brain & spine Surgery)
Minimal Access Surgery (Lasers & Transplants)

7. Which are the largest numbers of cases reported? (Please tick more than one if applicable)
1 Urology
2 Gastroenterology
3 Cardiology + Paediatrics Cardiology
4 Oncology
5 Orthopaedics (Knee / Hip Transplants)
6 Neurology (Brain & spine Surgery)
7 Minimal Access Surgery (Lasers & Transplants)

8. What could be the possible number of cases being addressed to ?(in a Year).
No. Of patients

1 Urology
2 Gastroenterology
3 Cardiology + Paediatrics Cardiology
4 Oncology
5 Orthopaedics (Knee / Hip Transplants)
6 Neurology (Brain & spine Surgery)
7 Minimal Access Surgery (Lasers & Transplants)
9. What are the possible number of patients visiting from near by villages/towns/cities?(in a Year)
No. of patients

1 Urology
2 Gastroenterology
3 Cardiology + Paediatrics Cardiology
4 Oncology
5 Orthopaedics (Knee / Hip Transplants)
6 Neurology (Brain & spine Surgery)
7 Minimal Access Surgery (Lasers & Transplants)

10. For Tertiary Care City do you refer your patients to?
Sl. No Hospital Speciality City
1 Bangalore
2 Mangalore
3 Belgaum
4 Mumbai
5 Others-
6 Others-
7 Others-

11. When you recommend patients to these Hospitals, what is the deciding factor?
1 Profile of Consultant
2 Hospital Name ( Brand Name )
3 Price
4 Patient Choice
5 Others(Please Specify)

12. How do you rate the services of existing Tertiary Care Hospitals?
1 2 3 4 5
Excellent Very Good Good Average Poor

13. Do you require Cath Lab Services?

Yes No

14. If Yes, Where do you refer your patients to?

a)__________________________________
b)__________________________________

15. Do the hospitals you recommend your patients to, lack something in specific?
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

16. What are the other Value Added Services you look for in a Hospital?
a)____________________________________________________________________
b)____________________________________________________________________
c)____________________________________________________________________
d)____________________________________________________________________

Thank You for your time.

17. Can we contact you in future for our further research?

Yes No

Contact Number: ____________________ email: _________________________________