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* 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 explain their role before they offered care?
Did staff explain your care to you in a way that you clearly understood?
Were you satisfied that you had enough say in decision making about your care? 

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* 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.)

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* 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?
Did staff treat you with courtesy and respect?
Were your preferences taken into account when providing care? 
Were you satisfied with the overall care you received today?

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* 4. I was given choices and involved in deciding how I manage my diabetes. 

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* 5. How have the sessions/classes helped you better manage your diabetes? Check all that apply.

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* 6. What would help you become more confident in managing diabetes?

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* 7. What do you value most about the program?

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* 8. What could the Diabetes Management Program do better?

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* 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.

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* 10. Would you recommend the Sioux Lookout Meno Ya Win Health Centre to friends and/or family?

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* 11. Is there anything else you would like to tell us about your most recent visit to the Sioux Lookout Meno Ya Win Health Centre?

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