Friends and Family Survey

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* 1. Thinking about your recent appointment, overall, how was your experience of our service?

Don't know

Very poor

Poor

Neither good nor poor

Good

Very good

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* 2. How satisfied were you with the service you received when in contact with GP Care?

0 - Not satisfied

10 - Extremely satisfied

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* 3. How clear and easy was it to understand the information we provided about your appointment?

0 - Not clear

10 - Extremely clear

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* 4. How satisfied were you with the service you received at your appointment?

0 - Not satisfied

10 - Extremely satisfied

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* 5. How well did the appointment meet your choice of location?

0 - Expectations not met

10 - Expectations fully met

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* 6. How well did the appointment meet your choice of time?

0 - Expectations not met

10 - Expectations fully met

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* 7. Have you been treated with dignity and respect by GP Care?

Yes

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* 8. Please could you explain why you gave those answers?

Organisations that provide healthcare for the NHS are required to collect information about the patients who use its services. The information on this form is collected to fulfil that obligation and to improve the services we provide. It is used for monitoring purposes only and ensures we treat all patients from across the community equally.

We will treat all personal information in line with current data protection legislation.

This form is entirely confidential. It is not traceable and does not affect the treatment you receive. Completion of the form is voluntary but please return it even if it is not complete.

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* 9. What is your gender?

Male

Female

Prefer not to say

Prefer to self-identify

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* 10. What is your age?

18-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

Prefer not to say

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* 11. What is your ethnic group?

White

Mixed/ Multiple ethnic groups

Asian/ Asian British

Black/ African/ Caribbean/ Black British

Other ethnic group

Prefer not to say

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* 12. 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, limited a lot

Yes, limited a little

Prefer not to say

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* 13. What service did you attend?

Ultrasound

Urology

DVT

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* 14. Name of the Clinician at your appointment

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* 15. Name of the Healthcare Assistant at your appointment

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* 16. Which clinic location did you visit? (e.g. Hadwen Medical Centre)

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* 17. Date of your appointment

Date / Time

Date