PLEASE READ BEFORE

ANSWERING:

SURVEY FORM for PATIENTS

This survey is being conducted in

connection with a legal research
entitled:
A CALL FOR EQUALITY
FOR PSYCHIATRIC
PATIENTS OF THE
PHILIPPINES:

YOUR IDENTITY WILL NOT BE REVEALED.

FOR YOUR CONVENIENCE:
YOU MAY HIGHLIGHT INSTEAD OF
CHECKING THE BOX
For answers with lines provided below,

Date: ______________________

The author of this research is

Naomi Therese F. Corpuz, a
student of the University of the
Philippines College of Law (U.P.
LAW) endorsed and supported by
the
Philippine
Psychiatric
Association, Inc. (PPA).

To be accomplished by the
facilitator/doctor:
(

) Caregiver

) Inpatient

Hospitals/Institution if Outpatient:
( ) Private Clinic
( ) Government Clinic

1) Age of the patient: _____________________________________

Sex of the patient: _______________________________________
2) Reason for consult: ___________________________ Diagnosis (if
known
to
patient/relative)____________________________________________
3) Services availed from Psychiatrist:
( ) Consultation at the Private Clinic / Follow up at the OPD
(Outpatient Department of Govt. run clinic)
( ) Hospital admission (for Inpatients)
( ) Home visits
( ) Group Sessions
( ) Others, please specify
________________________________________
4) How long have you been consulting a Psychiatrist?
( ) Less than 1 month ( ) Less than 1 year ( ) 1-2 yrs ( ) 3-4 yrs
( ) 5-6 yrs ( ) 7-8 yrs ( ) 9-10 yrs ( ) more than 10 yrs
5) Estimated number of consults in a year
( ) 1 consult
( ) 2-3 consults
( ) 4-5 consults

( ) 6 or more

6) Was this number of consults above (in no. 5)

( ) required by psychiatrist
( ) patients own decision
If answer above (no. 6) is patients own decision, why?
____________________________________________________________
Comments:
____________________________________________________________
____________________________________________________________
____________________________________________________________
6) How much do you spend in 1 consult (professional fee), pls specify:
________________________________
7) Where do you usually get you medications?
( ) Free:
( )from Government Institution ( )from my Doctor
( ) Purchased:
( ) from Drug Company
( ) with discount c/o (i.e. Senior citizen, etc)
at ( ) Hospital Pharmacy
( ) Drugstore
( ) Purchased without discount at the Drug Store

Hospitals/Institution if Inpatient:
( ) Private Psychiatric Facility
( ) Government Mental Institution
( ) Private Hospital
( ) Government General Hospital
( ) Others, please specify __________________
Location of Clinic/Hospital
( ) NCR
South Luzon
( ) Central Luzon
Mindanao

you MAY DELETE THE LINES and just

type your answer.

A Critique on their
Rights and Privileges in
Health Laws on the
Economic and Insurance
Aspects

Informant:
( ) Patient
(specify relationship): _____________________
Nature of Consult:
( ) Outpatient

Please take time to answer the following

questions.
The information you will provide will be
treated with UTMOST CONFIDENTIALITY.

( ) North Luzon

( )

( ) Visayas

( )

8) Estimated cost of medications in 1 month:

( ) Free ( ) P100 P500 ( ) P600 P 1000 ( ) P1, 500 P 2, 500
( ) P3000 P4, 500 ( ) P5000 and more
Comments:__________________________________________________
____________________________________________________________
____________________________________________________________
9) Estimated total expenses for consultations and medications in 1
MONTH:
( ) P500 P1000

(
(
(
(
(
(

) P1,500 P2,5000
) P3000 P5,000
) P5000 P10,000
) P10,000 P20,000
) P20,000 P30,000
) more than P30,000. If so, please specify amount:
___________________

Why? / Why not?

____________________________________________________________
_____________________________

9) Estimated total expenses for consultations and medications in 1 YEAR:

( ) P500 P1000
( ) P1,500 P2,5000
( ) P3000 P5,000
( ) P5000 P10,000
( ) P10,000 P20,000
( ) P20,000 P30,000
( ) more than P30,000. If so, please specify amount:
___________________

17) OTHER COMMENTS/SUGGESTIONS):

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

10) Reason/s for missing an appointment with your Psychiatrist:

( ) Forgetfulness
( ) Busy schedule
( ) Distance from Home
( ) Travel expenses
( ) Cost of Consult
( ) Others, pls specify:
_____________________________________
11) Most important reason for non-compliance with your medication
( ) Forgetfulness
( ) Unavailability. If so, please specify:________________
( ) Expense
( ) Others, pls specify:
______________________________________

12) Are you aware of the Magna Carta for Disabled

Persons (Republic Act 7277 as amended by Republic
Act 9244)?
( ) Yes
( ) No
Comments: ___________________________________
13) If yes, what can you comment or say about it?
_____________________________________________
____________________________________
14) If yes, Do you think you need to know more
about it?
( ) Yes
( ) No
Comments: ___________________________________
15) Is there a present Health Insurance Coverage for
psychiatric illnesses that you know of?
( ) Yes
( ) None
Comments: ___________________________________
16) What are your insights regarding health insurance
for psychiatric patients?
_____________________________________________
_____________________________________________
17) Have you heard of the pending National Mental Health Bill in
Congress?
( ) Yes
( ) No
18) Do you think you need to know more about this pending Bill?
( ) Yes
( ) No