Are you completing this as; Overall, are you getting the care that matters to you? 1 A patient Yes No Unsure 2 A friend / relative/ carer 3 A friend / care / relative filling this out on behalf of a patient ……………………………………………………………………………... Are you given enough information about the purpose of Which of the following services are you currently being your treatment? supported / cared for by? (tick all that apply) Always Sometimes No/ never 1 Community Nursing 2 Community Matron /VAWAS ……………………………………………………………………………... 3 Continence services 4 Coronary Heart Disease 5 Dietetics Do you get enough time to discuss your health 6 District nursing problems? 7 Intermediate care services Always Sometimes No/ never 8 Falls and Osteoporosis services 9 Physiotherapy ……………………………………………………………………………... 10 Podiatry 11 Speech and Language Therapy Are you involved as much as you want to be in ……………………………………………………………………………... decisions about your care? Approximately when did you first begin your treatment with Always Sometimes No/ never the service(s)? 1 months ago or …………………………………………………………………………... 2 years ago ……………………………………………………………………………... Do you know who to contact if you have any questions Overall, how would you rate the experience of the your care? service(s)? Yes No Unsure 1 Very good 2 Somewhat good …………………………………………………………………………... 3 Neither good nor poor 4 Somewhat poor 5 Very poor …………………………………………………………………………...
Are you completing this as; 1 A patient 2 A friend / relative/ carer 3 A friend / care / relative filling this out on behalf of a patient ……………………………………………………………………………... Which of the following services are you currently being supported / cared for by? (tick all that apply) 1 Community Nursing 2 Community Matron /VAWAS 3 Continence services 4 Coronary Heart Disease 5 Dietetics 6 District nursing 7 Intermediate care services 8 Falls and Osteoporosis services 9 Physiotherapy 10 Podiatry 11 Speech and Language Therapy ……………………………………………………………………………... Approximately when did you first begin your treatment with the service(s)? 1 months ago or 2 years ago ……………………………………………………………………………... Overall, how would you rate the experience of the service(s)? 1 Very good 2 Somewhat good 3 Neither good nor poor 4 Somewhat poor 5 Very poor …………………………………………………………………………... Overall, are you getting the care that matters to you? Yes No Unsure Are you given enough information about the purpose of your treatment? Always Sometimes No/ never ……………………………………………………………………………... Do you get enough time to discuss your health problems? Always Sometimes No/ never ……………………………………………………………………………... Are you involved as much as you want to be in decisions about your care? Always Sometimes No/ never …………………………………………………………………………... Do you know who to contact if you have any questions your care? Yes No Unsure …………………………………………………………………………...