Emergency Department FFT

Please tell us about your patient experience

Question Title

* 1. Date

Date / Time

Date

Question Title

* 2. Which department did you attend

Adults

Childrens

Thinking about your recent visit to our Emergency Department:

Question Title

* 3. Overall, how was your experience of our service?

Very good

Good

Neither good nor poor

Poor

Very poor

Don't know

Question Title

* 4. Please can you tell us why you gave your answer?

Question Title

* 5. Please tell us anything we could have done better.

Question Title

* 6. olijojo

Please tick this box if you DO NOT wish my comments to be made public

Question Title

* 7. What is your sex?

Male

Female

Non-gender conforming

Non-binary

Prefer not to say

Prefer to self-describe

Question Title

* 8. What age are you?

0-15

16-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

Question Title

* 9. What religion are you?

Christianity

Islam

Hiduism

Sikhism

Judaism

None

Prefer not to say

Other Religion

Question Title

* 10. What is your ethnic group?

White

Mixed/Multiple ethnic groups

Asian/Asian British

Black/African/Caribbean/Black British

Other (please specify)

Question Title

* 11. Are your day to day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? (include any issues/problems related to old age)

Yes

Prefer not to say