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Xyla Programme Feedback Form
Please answer the questions with as much detail as possible. Your feedback is very valuable to us.
20
Questions
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1
Name
First Name
Last Name
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2
Service user ID (if known)
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3
Which programme are you enrolled on/did you complete?
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4
Programme start date (if known)
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5
Are you happy for us to use your story for marketing purposes?
YES
NO
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6
If yes please select all that you are happy for your story to be shared on:
Social media
Xyla Health & Wellbeing website
Case study
I do not want my story to be used for marketing purposes
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7
What did you find most useful about your programme?
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8
What changes did you make to your lifestyle as a result of attending the programme, e.g. exercise routine, dietary habits?
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9
Have you accessed any local services (i.s. leisure centres, exercise on referral) due to this programme?
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10
What was your favourite part of the programme and why?
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11
What challenges did you face on the programme and how did you overcome them?
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12
What changes have you seen in any measurements that have been taken? E.g. weight, waist measurement, clothes size, blood glucose, blood pressure etc.
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13
Would you or have you recommended the programme to others? Why?
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14
What would you say to those who are thinking of joining the programme?
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15
Are there any other comments you wish to make about your experience?
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16
Are you happy to share any progress pictures with us? If so please upload them here:
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17
I agree to my name to be disclosed within marketing materials
YES
NO
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18
I agree to photos of myself to be used within marketing materials
YES
NO
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19
I wish to remain anonymous within marketing materials
YES
NO
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20
Signature
I hereby give permission for my story to be used by Xyla Health & Wellbeing and I consent to this being used for a 12 month period. Should you at any point wish to withdraw this consent you can do so by emailing
info@xylahealth.com.
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