Patient Stories Template

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In what capacity are you filling in this survey?

Patient

Carer

Family member (please state relationship)

Other (please specify):

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Comments:

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Do you, or the person you are completing the survey for have any long-term health conditions? If so, please tell us which one(s) in the comment box below.

Yes

Not sure

Other (please specify):

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Comments:

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Do you have any long-term health conditions? If so, please tell us which ones in the comments box.

Yes

Comments:

This is required

Please tell us in a few words the reason you are filling in this survey (e.g my experience of having diabetes or my visit to the urgent care centre).

What services looked after you and why did you need care?

Using the box below, please tell us about your experience, including the locations of any services you accessed.

Were there any barriers to you accessing the care that you needed?

Did you feel listened to and understood?

Yes

Not sure

Comments:

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Did you feel you involved in the decision about your care?

Yes

Not sure

Comments:

This is required

Did you feel there were options available to you?

Yes

Not sure

Comments:

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Overall was your experience positive or negative? Please tell us how we could have improved your experience?

Positive

Negative

Neutral

Other (please specify):

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Comments:

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Do you need to have any further or ongoing treatment?

Yes

If yes, please give details

This is required

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In what capacity are you filling in this survey?

Do you, or the person you are completing the survey for have any long-term health conditions? If so, please tell us which one(s) in the comment box below.

Do you have any long-term health conditions? If so, please tell us which ones in the comments box.

Please tell us in a few words the reason you are filling in this survey (e.g my experience of having diabetes or my visit to the urgent care centre).

What services looked after you and why did you need care?

Using the box below, please tell us about your experience, including the locations of any services you accessed.

Were there any barriers to you accessing the care that you needed?

Did you feel listened to and understood?

Did you feel you involved in the decision about your care?

Did you feel there were options available to you?

Overall was your experience positive or negative? Please tell us how we could have improved your experience?

Do you need to have any further or ongoing treatment?

If you have any further comments please let us know using the box below: