Friends and Family Test

We would like you to think about your recent experiences of our service/team

Your feedback will help us to improve the care we provide.

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* 1. Name of service

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* 2. Overall, how was your experience of our service?

Very good

Good

Neither good nor poor

Poor

Very poor

Don't know

Can you tell us why you gave that response?

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* 3. Is there anything we can do to make things better?

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* 4. Are you:

The patient / service user

A visitor

The carer

A friend

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* 5. What is your sex?

Male

Female

Prefer not to say

In your own words

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* 6. What best describes your ethnic background?

White

Mixed/Multiple ethnic groups

Asian/Asian British

Black/African/Caribbean/Black British

Other ethnic group

Prefer not to say

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* 7. Your age group:

0-15

16-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

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* 8. Are your day to day activities restricted because of a health problem or disability which has lasted, or is expected to last, at least 12 months?

Yes, limited a lot

Yes, limited a little

Prefer not to say

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* 9. Please tick this box if you DO NOT wish your comments to be made public

I do not wish for my comments to be made public