Outpatients FFT

Please tell us about your patient experience

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* 1. Date

Date / Time

Date

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* 2. Clinic

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* 3. Clinician

Thinking about your recent appointment:

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

Very good

Good

Neither good nor poor

Poor

Very poor

Don't know

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

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

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* 7. olijojo

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

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* 8. What is your sex?

Male

Female

Non-gender conforming

Non-binary

Prefer not to say

Prefer to self-describe

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* 9. What age are you?

0-15

16-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

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* 10. What religion are you?

Christianity

Islam

Hinduism

Sikhism

Judaism

None

Prefer not t o say

Other Religion

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* 11. What is your ethnic group?

White

Mixed/Multiple ethnic groups

Asian/Asian British

Black/African/Caribbean/Black British

Other (please specify)

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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

Prefer not to say