Patient Survey

English

Patient Survey

C3

1. Overall, how was your experience of our service?

Very good Good Neither good nor poor Poor Very poor Don't know

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2. Please can you tell us why you gave your answer and anything that we could have done better?

4000 characters remaining

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Can we share your comment publicly (for example, on our website or printed material such as posters)?

Yes No

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About you

We would like to know a bit more about you so that we can understand the experiences of people who use our services.

3. Are you?

The Patient Carer A Family Member Parent / Guardian

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4. Gender?

Male Female Self-describe Prefer not to say

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5. Age?

16 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75+ Prefer not to say

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6. Ethnicity?

White Mixed / Multiple ethnic groups Black / African / Caribbean / Black British Asian / Asian British Other ethnic group Prefer not to say

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7. Do you regard yourself as having a disability, impairment, or other condition that requires extra support or reasonable adjustments?

Yes No Prefer not to say

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8. If yes, did the hospital staff do everything they could to provide this support or adjustments?

Yes To some extent No Not applicable

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