Online Health Consultation Service (TeleMed) Needs Assessment Form for Foreigners Living in Indonesia

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Sec 1 is for respondents basic information

Can you tell us the first letter of your name (from A-Z)?

How do you describe your gender?

Female

Male

Prefer not to say

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How old are you? *

20-30 years old

30-40 years old

40-50 years old

Otro:

Where do you come from? *

Which city in Indonesia are you staying at? *

Jakarta

Bali

Other city in Java

Kalimantan

Otro:

How long have you been staying in Indonesia? *

Less than 1 year

1-2 years

More than 2 years

How long do you plan to stay in Indonesia? *

Less than 1 year

1-2 years

More than 2 years

Are you an expatriate?

Yes

Borrar selección

How is your ability to speak Bahasa? *

I can't speak Bahasa

I can speak Bahasa for my daily life

I can speak Bahasa at business level

I'm learning Bahasa

How is your ability to speak English? *

I'm fine in English

I can't speak English at all

I can speak English, but I prefer to use my native language (for non-English native)

Borrar formulario

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