Diabetes Village Patient Questionnaire We would value your feedback regarding your attendance at the Diabetes Village at the Merlyn Vaz Health Centre.Please answer the questions below. Your responses are important in the development of the Village. OK Question Title * 1. How did you hear about the Diabetes Village? Word of mouth Internet GP Practice Other health care provider, Who? Friend/family Advertisement Other (please specify) OK Question Title * 2. Did you visit the Merlyn Vaz Health and Social Care Centre today, specifically to use the services at the Diabetes Village? Yes No Other (please specify) OK Question Title * 3. Is this the first time you have used the Diabetes Village? Yes No OK Question Title * 4. If you have ticked yes, how many times have you visited the Village before? 1 - 3 4 - 6 7 - 10 10+ OK Question Title * 5. Which services did you use? Podiatry Eye Screening Type 2 Diabetes education Silver Star (including healthy eating, dietitian, exercise classes) Other (please specify) OK Question Title * 6. How would you rate your experience? Excellent Good Average Poor Please give the reason for your response OK Question Title * 7. How would you rate the location of the Diabetes Village? Excellent Good Average Poor Please give the reason for your response OK Question Title * 8. Would you attend the Diabetes Village again? Yes No Please give the reason for your response OK Question Title * 9. Would you recommend the Diabetes Village to family and friends? Yes No Please give the reason for your response OK Question Title * 10. Was it beneficial having all services under one roof? Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree Please give the reason for your response OK Question Title * 11. Do you have any further comments you wish to make? Is there anything else you wish to see at the Diabetes Village? OK Equality MonitoringPlease complete as much of the information about yourself as you feel comfortable with, as this will help us understand who is taking part in the consultation. The information you provide will be kept in accordance with the terms of the Data Protection Acts 1998 and 2000 and will be used for monitoring purposes and questionnaire analysis. OK Question Title * 12. What is your gender? Male Female Prefer not to say OK Gender reassignment OK Question Title * 13. Has your gender (sex) changed since birth? Yes No Prefer not to say OK Pregnancy/Maternity OK Question Title * 14. Are you pregnant or have you given birth in the last 26 weeks? Yes No Prefer not to say OK Age OK Question Title * 15. What is your age? Under 16 16 - 24 25 - 34 35 - 59 60 - 75 76+ Prefer not to say OK Disability OK Question Title * 16. Do you consider yourself to have a disability or suffer from poor health? Yes, I have a disability Yes, I am in poor health Neither Prefer not to say OK Condition OK Question Title * 17. If you have selected ‘yes’, please tell us which condition: Physical Partial or total loss of vision Learning disability/ difficulty Partial or total loss of hearing Mental health condition or disorder Long standing illness or disease Speech impediment or impairment Other medical condition or impairment, please tell us here OK Race OK Question Title * 18. What is your ethnicity? African Arab Bangladeshi Caribbean Chinese Gypsy/ Traveller Indian Irish Pakistani Polish Somali White British: English, Northern Irish, Scottish, Welsh Prefer not to say For mixed or other, please tell us here OK Religion or Belief OK Question Title * 19. What is your religion or belief? No religion Bahá’i Buddhist Christian Hindu Jain Jewish Muslim Sikh Prefer not to say Other (please specify) OK Relationship Status OK Question Title * 20. What is your relationship status? Single Married/civil partnership Separated or divorced Partnered/living with partner Widowed/surviving civil partner Prefer not to say OK Sexual Orientation OK Question Title * 21. What is your sexual orientation (preference)? Bisexual (relationship with either sex) Gay (male to male relationship) Heterosexual (male to female relationship) Lesbian (female to female relationship) Prefer not to say Other (please specify) OK DONE