Health Visiting Feedback

1. Service:

Health Visiting Learning Disability Nursing School Nursing

2. Reason for Contact:

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3. Where were you seen:

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5. Name of Practitioner you saw:

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	1	2	3	4	5
6. Did you feel listened to?
Notes:

6. Did you feel listened to?

1 2 3 4 5

7. Were you involved in decision making about you/your child?

1 2 3 4 5 N/A

	1	2	3	4	5	N/A
7. Were you involved in decision making about you/your child?
Notes:

8. Was the person you saw polite and professional?

1 2 3 4 5

	1	2	3	4	5
8. Was the person you saw polite and professional?
Notes:
9. Did they give you information in a way that you could understand?
Notes:
10. Was the place you were seen suitable for your needs?
Notes:

9. Did they give you information in a way that you could understand?

1 2 3 4 5

10. Was the place you were seen suitable for your needs?

1 2 3 4 5

11. Did you understand the care plan and next steps?

1 2 3 4 5 N/A

	1	2	3	4	5	N/A
11. Did you understand the care plan and next steps?
Notes:

If you were referred for a particular condition or concern please answer Q12-15 (Scale of 1 - 5 with 5 being the best)

	1	2	3	4	5
12. Have we made a positive difference by being involved with you and/or your child?
Notes:
13. Has your knowledge and understanding improved as a result of your contact with the service?
Notes:

12. Have we made a positive difference by being involved with you and/or your child?

1 2 3 4 5

13. Has your knowledge and understanding improved as a result of your contact with the service?

1 2 3 4 5

14. Have we increased your skills and confidence in managing your/your child’s condition?

1 2 3 4 5 N/A

	1	2	3	4	5	N/A
14. Have we increased your skills and confidence in managing your/your child’s condition?
Notes:

15. Do you know when and how to get further support if you need it?

1 2 3 4 5

	1	2	3	4	5
15. Do you know when and how to get further support if you need it?
Notes:

16. What did we do well?

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17. What could we have done better?

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18. Would you recommend the service?

Yes No

19. Name of Child and DOB (optional)

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Health Visiting Feedback

1. Service:

2. Reason for Contact:

3. Where were you seen:

4. Date of appointment:

5. Name of Practitioner you saw:

Scale of 1 - 5 questions with 5 being the best:

6. Did you feel listened to?

6. Did you feel listened to?

7. Were you involved in decision making about you/your child?

7. Were you involved in decision making about you/your child?

8. Was the person you saw polite and professional?

8. Was the person you saw polite and professional?

9. Did they give you information in a way that you could understand?

10. Was the place you were seen suitable for your needs?

9. Did they give you information in a way that you could understand?

10. Was the place you were seen suitable for your needs?

11. Did you understand the care plan and next steps?

11. Did you understand the care plan and next steps?

If you were referred for a particular condition or concern please answer Q12-15 (Scale of 1 - 5 with 5 being the best)

12. Have we made a positive difference by being involved with you and/or your child?

13. Has your knowledge and understanding improved as a result of your contact with the service?

12. Have we made a positive difference by being involved with you and/or your child?

13. Has your knowledge and understanding improved as a result of your contact with the service?

14. Have we increased your skills and confidence in managing your/your child’s condition?

14. Have we increased your skills and confidence in managing your/your child’s condition?

15. Do you know when and how to get further support if you need it?

15. Do you know when and how to get further support if you need it?

16. What did we do well?

17. What could we have done better?

18. Would you recommend the service?

19. Name of Child and DOB (optional)

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