| Thinking about your recent visit... |
| 1 | Thinking about the service we provide, overall, how was your experience of our service?
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| 2 | Please tell us anything that was particularly good
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| 3 | Please tell us about anything that we could have done better
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| 4 | I am treated with respect and dignity.
Being treated with respect and dignity means you are listened to, your feelings are considered, and people are kind, fair and polite.
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| We would be very grateful if you could answer some questions about you. You may wonder why we ask personal questions, or fear that your answers could affect your care in a negative way; in fact, the more you tell us about you, the better we can understand your needs. We can then give you care and treatment in the best way for you as an individual. Responding to these questions is entirely voluntary and any information provided will remain anonymous and treated in the strictest confidence. |
| 12 | Are you happy to answer some additional questions?
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| 13 | What is your postcode:
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| 14 | Please tell us your age:
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| 15 | What is your relationship status?
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| 16 | Are you currently pregnant?
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| 17 | Have you given birth within the last 12 months?
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| 18 | Do you consider yourself to have a disability or long term condition? This includes any health condition or disability that impacts on your daily life which you have had for 12 months or more. You may have learnt to manage your disability/long-term condition, but it still counts.
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| 19 | How would you describe your disability or long term condition?
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| Physical Condition / disability |
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Mental health condition |
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| Long term health condition |
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Neurodiversity |
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| Learning difficulty |
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Other long term health condition (please specify below) |
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| Other impairment (please specify below) |
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I do not wish to disclose whether or not I have a disability or long term condition |
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| N/A |
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| 20 | Ethnicity:
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| 21 | Please select your specific ethnicity:
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| 22 | Please select your specific ethnicity:
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| 23 | Please select your specific ethnicity:
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| 24 | Please select your specific ethnicity:
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| 25 | Please select your specific ethnicity:
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| 26 | Are you:
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| 27 | Is your gender identity the same as the gender you were given at birth?
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| 28 | Sexual Orientation:
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| 29 | Religion or Belief:
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