Diabetes Village Patient Questionnaire Survey

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* 1. How did you hear about the Diabetes Village?

Word of mouth

Internet

GP Practice

Other health care provider, Who?

Friend/family

Other (please specify)

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* 2. Did you visit the Merlyn Vaz Health and Social Care Centre today, specifically to use the services at the Diabetes Village?

Yes

Other (please specify)

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* 3. Is this the first time you have used the Diabetes Village?

Yes

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* 4. If you have ticked yes, how many times have you visited the Village before?

1 - 3

4 - 6

7 - 10

10+

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* 5. Which services did you use?

Podiatry

Eye Screening

Type 2 Diabetes education

Silver Star (including healthy eating, dietitian, exercise classes)

Other (please specify)

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* 6. How would you rate your experience?

Excellent

Good

Average

Poor

Please give the reason for your response

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* 7. How would you rate the location of the Diabetes Village?

Excellent

Good

Average

Poor

Please give the reason for your response

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* 8. Would you attend the Diabetes Village again?

Yes

Please give the reason for your response

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* 9. Would you recommend the Diabetes Village to family and friends?

Yes

Please give the reason for your response

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* 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

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* 11. Do you have any further comments you wish to make? Is there anything else you wish to see at the Diabetes Village?

Equality Monitoring
Please 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.

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* 12. What is your gender?

Male

Female

Prefer not to say

Gender reassignment

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* 13. Has your gender (sex) changed since birth?

Yes

Prefer not to say

Pregnancy/Maternity

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* 14. Are you pregnant or have you given birth in the last 26 weeks?

Yes

Prefer not to say

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* 15. What is your age?

Under 16

16 - 24

25 - 34

35 - 59

60 - 75

76+

Prefer not to say

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* 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

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* 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

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* 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

Religion or Belief

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* 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)

Relationship Status

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* 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

Sexual Orientation

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* 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)