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Friends and Family Card
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1. Are you completing this survey as a patient or carer?
For Information - Do you support somebody (friend, family, partner) that could not manage without your support due to their illness, frailty, disability, mental ill health, or substance misuse? If the answer is yes, you would be classed as a carer. A carer can be of any age.
Patient
Carer
Notes
2. Please enter your postcode (if you do not have a fixed abode please type N/A)
3. I think the help I had was...
Very good
Good
Neither good nor poor
Poor
Very poor
Don't know
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4. I think this because.....
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Can we share your comment publicly (for example, on our website or printed material such as posters)?
Yes
No
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5. 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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6. What did we do well?
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Notes
7. What could we do better?
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Can we share your comment publicly (for example, on our website or printed material such as posters)?
Yes
No
Notes
8. We routinely collect information on age, gender, ethnicity and sexual orientation to ensure that we are receiving feedback from a wide range of people about our services. The following questions help us to monitor if we are hearing from everyone. Please choose a response to continue:
I'm happy to answer these questions
I don't want to answer these questions
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9. What is your age group?
18 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 - 74
75+
Under 18
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10. To which of these ethnic groups would you say you belong?
Please type the first few letters...
Asian or Asian British - Any other Asian background
Asian or Asian British - Bangladeshi
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Black or Black British - African
Black or Black British - Any other Black background
Black or Black British - Caribbean
Mixed - Any other mixed background
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Not known
Not stated
Other Ethnic Groups - Any other ethnic group
Other Ethnic Groups - Chinese
White - Any other background
White - British
White - Irish White
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11. Gender?
Female
Male
Transgender
Prefer not to say
I prefer to self-describe
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12. I describe myself as:
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Notes
13. What is your sexual orientation?
Heterosexual or Straight
Gay or Lesbian
Bisexual
Other sexual orientation not listed
Do not know or not sure
I prefer not to answer
I prefer to self-describe
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14. I describe myself as:
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Notes
Submit
Thank you for your feedback.
Submit