Formic Web Forms - [5 FFT Community SH HIV April 2020

5 FFT Community SH HIV April 2020

Tell us what you think about the quality of your care!

V1-2020

Thinking about your recent experience of our Community Service...

Alternatively you can complete an online form at https://www.cht.nhs.uk/patients-visitors/family-and-friends-test

Equality Monitoring

Date of feedback:

What could we do better?

Which service have you been seen by?

If yes, please state:

What went well with your care and treatment?

Do you have a disability?

Yes

Prefer not to say

What is your age?

55-64

16-24

0-15

35-44

65-74

75+

25-34

45-54

Prefer not
to say

If you DO NOT wish your anonymous comments to be used in our promotional material, please tick here:

Overall, how was your experience of our service?

Good

Neither Good
nor Poor

Very
Poor

Poor

Don't
know

Very
Good

What is your sexual orientation?

Heterosexual

Gay-Lesbian

Bisexual

Prefer not to say

Are you male or female?

Female

Prefer to use
my own term

Male

Prefer not to say

What is your ethnic group?

Mixed

White

Asian

Prefer not to say

Black

Other

I am answering this as a...

Patient

Relative/Carer/Advocate
(please answer the questions below
about the patient)

HIV

Sexual Health

Yorkshire Fertility