Women's College Hospital Environmental Health Clinic Quality and Impact of Care Survey

Question Title

* 3. Which of the following was diagnosed during your time at the Environmental Health Clinic?

MCS (multiple chemical sensitivity)

CFS/ME (chronic fatigue syndrome, myalgic encephalomyelitis)

FM (fibromyalgia)

EHS (electromagnetic hypersensitivity)

Other (please specify)

Question Title

* 4. Do you have other chronic illnesses in addition to environmental illness?

Yes

Please comment (optional)

Question Title

* 5. In what year was your initial assessment at the EHC?

Question Title

* 6. How many years has it been since your final visit at the EHC?

Question Title

* 7. Approximately how many years have you been unwell with the condition that brought you to the EHC?

Question Title

* 8. Before my experience at the EHC, I had the following:

positive engagement in life

active engagement in life

participation in things that make me happy in life

Other (please specify)

Question Title

* 9. After my experience at the EHC, I had the following:

positive engagement in life

active engagement in life

participation in things that make me happy in life

Other (please specify)

Question Title

* 10. Before my experience at the EHC, I was able to engage in exercise or healthy activities.

1 (Strongly Disagree)

Neutral

5 (Strongly Agree)

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 11. After my experience at the EHC, I am able to engage in exercise or healthy activities.

1 (Strongly Disagree)

Neutral

5 (Strongly Agree)

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 12. Please add any further comment below:

Question Title

* 13. Before my experience at the EHC, I had strategies that helped me cope.

1 (Strongly Disagree)

Neutral

5 (Strongly Agree)

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 14. After my experience at the EHC, I had strategies that helped me cope.

1 (Strongly Disagree)

Neutral

5 (Strongly Agree)

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 15. Please add any further comment below:

Question Title

* 16. Before my experience at the EHC, I had the social support resources I needed to manage the demands of my illness.

1 (Strongly Disagree)

Neutral

5 (Strongly Disagree)

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 17. After my experience at the EHC, I had the social support resources I needed to manage the demands of my illness.

1 (Strongly Disagree)

Neutral

5 (Strongly Disagree)

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 18. Please add any further comment below:

Question Title

* 19. Before my experience at the EHC, I was able to engage in the following activities:

personal self-care (including hygiene/grooming, dressing, bathing)

groceries and meal preparation

cleaning and maintaining my home

walking

everyday travel

none of the above

Other (please specify)

Question Title

* 20. After my experience at the EHC, I was able to engage in the following activities:

personal self-care (including hygiene/grooming, dressing, bathing)

groceries and meal preparation

cleaning and maintaining my home

walking

everyday travel

none of the above

Other (please specify)

Question Title

* 21. During my time at the EHC, I experienced the following challenges to accessing the clinic:

parking

travel time

distance

traffic congestion

exposures

I experienced no challenges

Other (please specify)

Question Title

* 22. During my time at the EHC, I experienced the following:

confidence with the doctors and staff

positive relationships

my needs were met

I felt we worked as a team

none of the above

Other (please specify)

Question Title

* 23. Overall, after my experiences at the EHC, I feel more hopeful in my ability to manage my illness effectively.

Strongly Disagree

Disagree

Neither agree or disagree

Agree

Strongly agree

Other (please specify)

Question Title

* 24. I felt as though the EHC had the resources it needed to support quality of care DURING my time at the EHC.

Strongly Disagree

Disagree

Neither agree nor disagree

Agree

Strongly Agree

Question Title

* 25. I felt as though the EHC had the resources it needed to support quality of care AFTER my time at the EHC.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Other (please specify)

Question Title

* 26. To what extent would you say your experience at the EHC has contributed to an improvement in your condition?

To a very limited extent

To a limited extent

Neutral, the EHC did not impact my overall condition

To a great extent

To a very great extent

Other (please specify)

Question Title

* 27. I feel as though the EHC was able to effectively coordinate a transition to continuing forms of care after my last visit.

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

Other (please specify)

Question Title

* 28. Please indicate if any of the following needs are not currently being addressed by health care practitioners ( such as GP, medical specialists):

help with disability forms

referrals to other allied healthcare professionals

lab tests

appropriate medical care

prescriptions

psychosocial support

connecting with community services

all of my needs are currently being met

Other (please specify)

Question Title

* 29. Have new environmentally-linked conditions arisen since your time at the EHC? Please select all that apply.

Yes- unspecified

No new conditions have arisen since I have visited the clinic

Yes- possibly MCS

Yes- possibly CFS/ME

Yes- possibly FM

Yes- possibly EHS (electromagnetic hypersensitivity)

Yes- possibly heavy metal toxicity

Yes- possibly mould exposure

Other (please specify)

Question Title

* 1. What is your age?

Question Title

* 2. Town of residence in Ontario (optional):

Question Title

* 3. Which of the following was diagnosed during your time at the Environmental Health Clinic?

Question Title

* 4. Do you have other chronic illnesses in addition to environmental illness?

Question Title

* 5. In what year was your initial assessment at the EHC?

Question Title

* 6. How many years has it been since your final visit at the EHC?

Question Title

* 7. Approximately how many years have you been unwell with the condition that brought you to the EHC?

Question Title

* 8. Before my experience at the EHC, I had the following:

Question Title

* 9. After my experience at the EHC, I had the following:

Question Title

* 10. Before my experience at the EHC, I was able to engage in exercise or healthy activities.

Question Title

* 11. After my experience at the EHC, I am able to engage in exercise or healthy activities.

Question Title

* 12. Please add any further comment below:

Question Title

* 13. Before my experience at the EHC, I had strategies that helped me cope.

Question Title

* 14. After my experience at the EHC, I had strategies that helped me cope.

Question Title

* 15. Please add any further comment below:

Question Title

* 16. Before my experience at the EHC, I had the social support resources I needed to manage the demands of my illness.

Question Title

* 17. After my experience at the EHC, I had the social support resources I needed to manage the demands of my illness.

Question Title

* 18. Please add any further comment below:

Question Title

* 19. Before my experience at the EHC, I was able to engage in the following activities:

Question Title

* 20. After my experience at the EHC, I was able to engage in the following activities:

Question Title

* 21. During my time at the EHC, I experienced the following challenges to accessing the clinic:

Question Title

* 22. During my time at the EHC, I experienced the following:

Question Title

* 23. Overall, after my experiences at the EHC, I feel more hopeful in my ability to manage my illness effectively.

Question Title

* 24. I felt as though the EHC had the resources it needed to support quality of care DURING my time at the EHC.

Question Title

* 25. I felt as though the EHC had the resources it needed to support quality of care AFTER my time at the EHC.

Question Title

* 26. To what extent would you say your experience at the EHC has contributed to an improvement in your condition?

Question Title

* 27. I feel as though the EHC was able to effectively coordinate a transition to continuing forms of care after my last visit.

Question Title

* 28. Please indicate if any of the following needs are not currently being addressed by health care practitioners ( such as GP, medical specialists):

Question Title

* 29. Have new environmentally-linked conditions arisen since your time at the EHC? Please select all that apply.

Question Title

* 30. Do you have any other comments, questions, or concerns?