[NAME OF MEDICAL CARE PROVIDER......]
Are they confident in (PROVIDER)'s ability to help when they have a medical problem?

YES ..................................... 1
NO ...................................... 2
REF ..................................... -7
DK ...................................... -8

[NAME OF MEDICAL CARE PROVIDER......]
Are they confident in (PROVIDER)'s ability to help when they have a medical problem?

YES ..................................... 1
NO ...................................... 2
REF ..................................... -7
DK ...................................... -8

[NAME OF MEDICAL CARE PROVIDER......]
Are they confident in (PROVIDER)'s ability to help when they have a medical problem?

YES ..................................... 1
NO ...................................... 2
REF ..................................... -7
DK ...................................... -8

[NAME OF MEDICAL CARE PROVIDER......]
Are they confident in (PROVIDER)'s ability to help when they have a medical problem?

YES ..................................... 1
NO ...................................... 2
REF ..................................... -7
DK ...................................... -8

[NAME OF MEDICAL CARE PROVIDER......]
Are they confident in (PROVIDER)'s ability to help when they have a medical problem?

YES ..................................... 1
NO ...................................... 2
REF ..................................... -7
DK ...................................... -8

[NAME OF MEDICAL CARE PROVIDER......]
Are they confident in (PROVIDER)'s ability to help when they have a medical problem?

YES ..................................... 1
NO ...................................... 2
REF ..................................... -7
DK ...................................... -8