Diabetes Program Client Experience Survey Question Title * 1. Please answer the following questions about your visit today. Always Usually Sometimes Rarely Never Don't Know/Not Applicable Did staff introduce themselves to you? Did staff introduce themselves to you? Always Did staff introduce themselves to you? Usually Did staff introduce themselves to you? Sometimes Did staff introduce themselves to you? Rarely Did staff introduce themselves to you? Never Did staff introduce themselves to you? Don't Know/Not Applicable Did staff explain their role before they offered care? Did staff explain their role before they offered care? Always Did staff explain their role before they offered care? Usually Did staff explain their role before they offered care? Sometimes Did staff explain their role before they offered care? Rarely Did staff explain their role before they offered care? Never Did staff explain their role before they offered care? Don't Know/Not Applicable Did staff explain your care to you in a way that you clearly understood? Did staff explain your care to you in a way that you clearly understood? Always Did staff explain your care to you in a way that you clearly understood? Usually Did staff explain your care to you in a way that you clearly understood? Sometimes Did staff explain your care to you in a way that you clearly understood? Rarely Did staff explain your care to you in a way that you clearly understood? Never Did staff explain your care to you in a way that you clearly understood? Don't Know/Not Applicable Were you satisfied that you had enough say in decision making about your care? Were you satisfied that you had enough say in decision making about your care? Always Were you satisfied that you had enough say in decision making about your care? Usually Were you satisfied that you had enough say in decision making about your care? Sometimes Were you satisfied that you had enough say in decision making about your care? Rarely Were you satisfied that you had enough say in decision making about your care? Never Were you satisfied that you had enough say in decision making about your care? Don't Know/Not Applicable Question Title * 2. Were you or your caregiver asked what your NEEDS or CULTURAL VALUES are when making decisions about your care?(Your unique needs, customs, beliefs, rituals, traditions, such as any or all of the following: accessibility needs; dietary restrictions such as gluten-free, vegetarian, etc.; interpreter assistance for all languages; family members or close friends present; visits by clergy members, elders, or spiritual leaders; visits to the multi-denominational chapel; access to the traditional ceremonial room; traditional healing options; sacraments or sacred rituals; who you would like to make decisions about your care if not you; etc.) Yes, always Usually Sometimes Never Question Title * 3. Please answer the following questions about your visit today. Always Usually Sometimes Never Don't Know/Not Applicable Were you satisfied with the customer service from our staff? Were you satisfied with the customer service from our staff? Always Were you satisfied with the customer service from our staff? Usually Were you satisfied with the customer service from our staff? Sometimes Were you satisfied with the customer service from our staff? Never Were you satisfied with the customer service from our staff? Don't Know/Not Applicable Did staff treat you with courtesy and respect? Did staff treat you with courtesy and respect? Always Did staff treat you with courtesy and respect? Usually Did staff treat you with courtesy and respect? Sometimes Did staff treat you with courtesy and respect? Never Did staff treat you with courtesy and respect? Don't Know/Not Applicable Were your preferences taken into account when providing care? Were your preferences taken into account when providing care? Always Were your preferences taken into account when providing care? Usually Were your preferences taken into account when providing care? Sometimes Were your preferences taken into account when providing care? Never Were your preferences taken into account when providing care? Don't Know/Not Applicable Were you satisfied with the overall care you received today? Were you satisfied with the overall care you received today? Always Were you satisfied with the overall care you received today? Usually Were you satisfied with the overall care you received today? Sometimes Were you satisfied with the overall care you received today? Never Were you satisfied with the overall care you received today? Don't Know/Not Applicable Question Title * 4. I was given choices and involved in deciding how I manage my diabetes. Strongly Agree Agree Neutral Disagree Strongly Disagree Question Title * 5. How have the sessions/classes helped you better manage your diabetes? Check all that apply. More knowledge of diabetes More knowledge of medication Aware of possible health complications Know which tests I need to do and why Setting goals for myself Personal support/encouragement from staff Improved nutrition/healthy food choices Increased physical activity Spouse/family better able to support me Increased confidence that I can manage my diabetes The sessions have not helped me Other (please specify) Question Title * 6. What would help you become more confident in managing diabetes? Question Title * 7. What do you value most about the program? Question Title * 8. What could the Diabetes Management Program do better? Question Title * 9. Please rate SLMHC using any number from 1 - 10, where 1 is the WORST health centre possible and 10 is the BEST health centre possible. 10 - Best 9 8 7 6 5 4 3 2 1 - Worst 10 - Best 9 8 7 6 5 4 3 2 1 - Worst Question Title * 10. Would you recommend the Sioux Lookout Meno Ya Win Health Centre to friends and/or family? Definitely Yes Probably Yes Probably No Definitely No Unsure Question Title * 11. Would you like to add your name to a list of clients to be contacted for input on future SLMHC projects/changes? Yes No If yes, please enter your name and preferred method of contact (email address or phone number). Question Title * 12. Is there anything else you would like to tell us about your most recent visit to the Sioux Lookout Meno Ya Win Health Centre? Submit Survey
