Friends & Family Test

Friends and Family Test Questionnaire
Thinking about your recent visit...
Overall, how was your experience of our service?*

Very goodGoodNeither good nor poorPoorVery poorDon't know
Please can you tell us why you gave your answer?*
Please tell us about anything that we could have done better
Please tick here if you DO NOT want your comments to be public

Optional inclusivity questions
We want to make sure that everybody is included when asking the Friends and Family Test question, please complete the following questions so that we can make sure that all of our patients have the opportunity to give their views

Please select the correct answer
What is your gender?

FemaleMaleTransgender
What is your age?

Under 1818 - 2526 - 3435 - 4445 - 5455 - 6465+
What is your ethnic group?

AsianBlackMixedWhiteOther
Asian

British - IndianBritish - PakistaniBritish - BangladeshiBritish - ChineseIndianPakistaniBangladeshiChinese
Black

British - CaribbeanBritish - AfricanCaribbeanAfrican
Mixed

White and BlackWhite and AsianMixed backgroundCaribbeanAfrican
White

BritishEnglishScottishIrishWelshIrish Traveler/ White GypsyEuropeanNon- European
Do you consider yourself to have a disability?

YesNoPrefer not to say
Please indicate the type of impairment which applies to you. If your experience more than one type of impairment, please tick all the types that apply. If your disability does not fit any of these types, please mark Other and specify.

Physical/ mobility imparirment, such as a difficulty using your arms or mobility issues which require you to use a wheelchair or crutchesVisual impairment, such as being blind or having a serious visual impairmentHearing impairment, such as being deaf or having a serious hearing impairmentMental health condition, such as depression or schizophreniaLearning disability/difficulty, such as Down's syndrome or dyslexia or a cognitive impairment such as autistic spectrum disorderLong-standing illness or health condition, such as cancer, HIV, diabetes, chronic heart disease or epilepsyOther
Should be Empty:

Friends and Family Test Questionnaire

Optional inclusivity questions