I. EXPERIENCE WITH THE HEALTH CARE SYSTEM

Please circle a letter for each question and fill in the blank if appropriate.

Do the self-advocates in your program live primarily in an area that is:

a) Urban     b) Suburban     c) Rural

How many of the self-advocates in your program have a primary care physician?

a) All
b) Most
c) Half
d) Some
e) None

How many of the self-advocates in your program received routine medical exam in the past 12 months?

a) All
b) Most
c) Half
d) Some
e) None

How many of the self-advocates in your program required urgent care at least once in the past 12 months?

a) All
b) Most
c) Half
d) Some
e) None

What kind of physician do most of the self-advocates in your program usually see?

a) Family Practice MD
b) Internist
c) Psychiatrist
d) Neurologist
e) Pediatrician
f) Other (please specify)_______________________________________

Check all types of health care professional that self-advocates in your program have seen in the past 12 months.

a) Nurse _____
b) Occupational Therapist _____
c) Physical Therapist _____
d) Social Worker _____
e) Psychologist _____
f) Nutritionist _____
g) Speech therapist _____

How comfortable are you with the self-advocates' physicians or other health care providers during an appointment?

a) Very uncomfortable
b) Uncomfortable
c) Somewhat uncomfortable
d) Somewhat comfortable
e) Comfortable
f) Very comfortable

How satisfied are you generally with the health care the self-advocates in your program receive?

a) Very unsatisfied
b) Unsatisfied
c) Somewhat unsatisfied
d) Somewhat satisfied
e) Satisfied
f) Very satisfied

II. BARRIERS TO RECEIVING GOOD HEALTH CARE SERVICES

Please consider each of the potential barriers to health care and rate them from 1 to 5. "1" is a
low barrier; "5" is a high barrier.

III. Please list any suggestions you have that might make it easier to provide medical care for adults with developmental disabilities.

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Is there anything else we ought to know about providing medical care for this population?

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