Brockhurst Patient Survey Question Title * 1. Are you registered as a patient at Brockhurst Medical Centre? Yes – just me Yes – and my family is No – I am a carer for a patient at Brockhurst Medical Centre? No OK Question Title * 2. Roughly how often do you use Brockhurst Medical Centre? Once a week Once a fortnight Once a month Once or twice a year Less often OK Question Title * 3. How do you usually travel to this surgery? By foot Own car Public Transport Taxi Bicycle Other (please specify) OK Question Title * 4. Approximately how long does it usually take you to get to the surgery? Less than 10 minutes More than 10 minutes but less than 15 minutes More than 15 minutes OK Question Title * 5. If you have not used the surgery over the last year, why is this? Opening hours Difficult access No need to go to the Doctors Services not provided OK Question Title * 6. Which of the available services would you say you most often use at the surgery? Appointment with a GP – (including face-to-face, telephone or online eg eConsult or Skye or similar) Appointment with a Nurse – (including face-to-face, telephone or online eg eConsult or Skye or similar) Ante-natal services Regular blood tests Minor Surgery Vaccination clinics Other OK Question Title * 7. What is important to you in receiving a service from your surgery? Please rank 1 - 5 where 1 is most important and 5 least important. 1 2 3 4 5 Distance to travel 1 2 3 4 5 Easy access 1 2 3 4 5 Opening hours 1 2 3 4 5 Range of services 1 2 3 4 5 Choice of Doctor/Nurse OK Question Title * 8. Are you Male Female Prefer not to say OK Question Title * 9. Your age 17 or under 18-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ OK Question Title * 10. Your ethnic background Indian Pakistani Bangladeshi Nepali Asian background Black Caribbean Black African Any other Black background Chinese White and Black Caribbean White and Black African White and Asian White British White Irish Any other white background Prefer not to say OK Question Title * 11. Are you a carer? No Yes for a child/children under 18 years living at home Yes, for a relative or person living with you Yes, for a relative or person living elsewhere OK Thank you for taking the time to complete this survey. OK DONE
