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EXAMPLE SURVEY

EXAMPLE SURVEY
Patient Survey
Please complete this short survey.
It will help us improve what we do.

1. Date of survey *This question is required. This question requires a valid date format of DD/MM/YYYY.

calendar

2. Contact Type

3. How are you today? (past 24 hours)
How do you feel and how much can you do?
Choose one answer on each line

Space Cell	None	A little	Quite a lot	Extreme
Pain or discomfort	Pain or discomfort: None	Pain or discomfort: A little	Pain or discomfort: Quite a lot	Pain or discomfort: Extreme
Feeling low or worried	Feeling low or worried: None	Feeling low or worried: A little	Feeling low or worried: Quite a lot	Feeling low or worried: Extreme
Limited in what I can do	Limited in what I can do: None	Limited in what I can do: A little	Limited in what I can do: Quite a lot	Limited in what I can do: Extreme
Require help from others	Require help from others: None	Require help from others: A little	Require help from others: Quite a lot	Require help from others: Extreme

4. Health Confidence
How do you feel about caring for your health?
How much do you agree?

Space Cell	Strongly agree	Agree	Neutral	Disagree
I know enough about my health	I know enough about my health: Strongly agree	I know enough about my health: Agree	I know enough about my health: Neutral	I know enough about my health: Disagree
I can look after my health	I can look after my health: Strongly agree	I can look after my health: Agree	I can look after my health: Neutral	I can look after my health: Disagree
I can get the right help if I need it	I can get the right help if I need it: Strongly agree	I can get the right help if I need it: Agree	I can get the right help if I need it: Neutral	I can get the right help if I need it: Disagree
I am involved in decisions about me	I am involved in decisions about me: Strongly agree	I am involved in decisions about me: Agree	I am involved in decisions about me: Neutral	I am involved in decisions about me: Disagree

5. How are we doing?
What do you think about our service?
Choose one answer on each line

Space Cell	Excellent	Good	Fair	Poor
Treat me kindly	Treat me kindly: Excellent	Treat me kindly: Good	Treat me kindly: Fair	Treat me kindly: Poor
Listen and explain	Listen and explain: Excellent	Listen and explain: Good	Listen and explain: Fair	Listen and explain: Poor
See me promptly	See me promptly: Excellent	See me promptly: Good	See me promptly: Fair	See me promptly: Poor
Well organised	Well organised: Excellent	Well organised: Good	Well organised: Fair	Well organised: Poor

6. Age Group
What age group are you?

7. Gender
Are you (the patient)?

8. Medications
How many different types of prescribed medicines do you take each day?

9. Comments
Please add any comments to explain any of your answers (optional)