1. How do you Feel About the Care You Have Received?

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This questionnaire will help to look into the levels of service you received in health care. Please take the time to give your honest opinion on each of the questions, as this will help us to drive an improvement in service. All your answers will be kept in the strictest of confidentiality. If you have any questions about this survey, please contact [NAME] on [TELEPHONE] or [EMAIL].

Thank you in advance for the help you are giving us.

Which local authority do you live in?

If there are several hospitals in your area, are there differences in services?

Yes

Don't Know / Only One Hospital in My Area

Do you have a preference for which hospital you go to?

Yes

Do you usually go to the same hospital?

Yes

Are you able to judge the difference between the various hospitals?

Yes

N/A

Could you help your friends in choosing the best hospital for them?

Yes

Don't Know

Does your family pressure you to have any medical needs seen to straight away?

Yes

Sometimes

The hospital has all necessary equipment for treatment and diagnosis.

Yes

Don't Know

The Hospital has Modern Operating Rooms.

Yes

Don't Know

What kind of medical insurance do you currently hold?

None

Employer sponsored

Private

Medicare

Medicaid

Not Sure

Other, please specify:

This is required

How often have you or a member of your family visited the doctor in the past 12 months?

How often have you visited someone in hospital in the past 12 months?

If you had a personal injury that could be treated at any clinic, which clinic would you prefer?

Walk-in clinic

Your Own Doctor

A&E Room at Hospital

Other, please specify:

This is required

If you received medical care at a hospital outside of your area, why did you do so?

Availability of Specialist

Special Care was Not Available in My Own Hospital

My Own Physician Works in the Other Hospital

I am Familiar with the Hospital

Second Opinion

Religious Ideas

Other, please specify:

This is required

Who makes decisions about health care in your family?

Who decides which hospital should be used?

You

You, with Information from Your Physician

Joint Decision Between You and the Physician

Your Physician, with Information from You

Your Physician

Varies

What treatment have you heard people receive at the hospital you have gone to?

The following questions help us to monitor the demographics of our respondents. We need these to ensure we can offer the best service to people in all age, gender and race sections of the population. Naturally, these results will be fully confidential.

Your Gender:

Male

Female

Your Age:

Age or Ages of Child(ren) in Your Household (please tick all that apply)

Under 12

Between 12 and 18

Over 18

What is Your Marital Status?

Married or Living Together

Divorced or Separated

Widowed

Unmarried

What is your total annual household income before tax?

Lower than £10,000

Between £10,000 and £24,999

Between £25,000 and £49,999

Between £50,000 and £74,999

Between £75,000 and £99,999

Over £100,000

Please indicate your highest level of completed schooling:

Secondary School

College or Sixth Form

University

Health Care Opinion Survey