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* 1. Gender

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* 2. Age

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* 3. Ethnic origin

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* 4. What is your marital status

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* 5. Postcode

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* 6. Do you consider yourself to have a disability?

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* 7. Which health and social care services have you used in the last 12 months? (please tick all that apply)

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* 8. On average, how regularly do you visit these services? (please tick appropriate box)

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* 9. How easy do you find booking appointments?

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* 10. Are you accompanied by a family member, friend, or carer when attending appointments?

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* 11. Are you confident accessing services on your own or would you prefer additional support? If so, what support would you prefer?

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* 12. Do you feel staff are on hand to help you if needed?

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* 13. Are you satisfied with the care and treatment you have received at your appointments? (please tick appropriate box)

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* 14. Has there ever been a time that you haven’t attended your appointment?

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* 15. If unable to attend an appointment in the past, did you find it difficult to rearrange?

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* 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
Skype/video consultation
Online booking of appointments
Use of text, fax or Typetalk

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* 17. Do you feel confident in using online services?

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* 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?

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* 19. Do you have any concerns for your future care? If so, please explain.

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* 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?

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* 21. What do you consider as your biggest priority in regards to your health and wellbeing?

T