Share Your Experience - Shape Our Priorities Question Title * 1. Gender Female Male Prefer not to say OK Question Title * 2. Age 50 and under 51-55 56-60 61-65 66-70 71-75 76-80 81-85 86+ Prefer not to say OK Question Title * 3. Ethnic origin White Asian / British Asian Black / African / Caribbean / Black British Mixed / Multiple Ethnicities Other Ethnic Group Prefer not to say OK Question Title * 4. What is your marital status Single Long-term relationship Civil partnership Married Widowed Divorced Prefer not to say OK Question Title * 5. Postcode OK Question Title * 6. Do you consider yourself to have a disability? No Yes OK Question Title * 7. Which health and social care services have you used in the last 12 months? (please tick all that apply) GP Hospital Optician Audiologist Dentist Pharmacy GP Out of Hours Social Care Other (please specify) OK Question Title * 8. On average, how regularly do you visit these services? (please tick appropriate box) Weekly Monthly Few times a year Annually OK Question Title * 9. How easy do you find booking appointments? Easy (no problems) Sometimes struggle (a few problems) Very difficult (a lot of problems) Can you tell us the main reasons behind this? OK Question Title * 10. Are you accompanied by a family member, friend, or carer when attending appointments? OK Question Title * 11. Are you confident accessing services on your own or would you prefer additional support? If so, what support would you prefer? OK Question Title * 12. Do you feel staff are on hand to help you if needed? OK Question Title * 13. Are you satisfied with the care and treatment you have received at your appointments? (please tick appropriate box) Always Most of the time Rarely Never Comments OK Question Title * 14. Has there ever been a time that you haven’t attended your appointment? No (I have never missed an appointment) Yes (I have missed an appointment) If answered yes, can you tell us why? OK Question Title * 15. If unable to attend an appointment in the past, did you find it difficult to rearrange? No (not difficult) Yes (difficult) If answered yes, can you tell us why? OK Question Title * 16. Going to see your GP is not the only way to access healthcare services. Some practices offer telephone and video consultations with a GP, an online booking system for appointments and repeat prescriptions. What do you think about these? I would definitely use this option I might use this option sometimes I would never use this option Don't know I already use this option Phone consultation Phone consultation I would definitely use this option Phone consultation I might use this option sometimes Phone consultation I would never use this option Phone consultation Don't know Phone consultation I already use this option Skype/video consultation Skype/video consultation I would definitely use this option Skype/video consultation I might use this option sometimes Skype/video consultation I would never use this option Skype/video consultation Don't know Skype/video consultation I already use this option Online booking of appointments Online booking of appointments I would definitely use this option Online booking of appointments I might use this option sometimes Online booking of appointments I would never use this option Online booking of appointments Don't know Online booking of appointments I already use this option Use of text, fax or Typetalk Use of text, fax or Typetalk I would definitely use this option Use of text, fax or Typetalk I might use this option sometimes Use of text, fax or Typetalk I would never use this option Use of text, fax or Typetalk Don't know Use of text, fax or Typetalk I already use this option OK Question Title * 17. Do you feel confident in using online services? I feel confident I don't feel confident, but I try to use I would feel more confident with more guidance I don't feel confident at all and don't like to use I have never tried to use OK Question Title * 18. Do you feel there is enough support available to you within your local community that allows you to live as independently as you want? Yes, there is enough community support for me No, there is not enough community support for me I don’t know of any community support on offer I don't need any community support Comments OK Question Title * 19. Do you have any concerns for your future care? If so, please explain. No Yes If answered yes, can you tell us why? OK Question Title * 20. Have you had any experiences within the health and social care services over the past 12 months that you would like to share with us; is there anything that you feel needs improving or is there something that has worked well for you? OK Question Title * 21. What do you consider as your biggest priority in regards to your health and wellbeing? OK DONE