Your details

I'm a . . .

Patient Relative Friend of the patient

Hospital

Ward at K&C

Ward at QEQM

Ward at WHH

Gender

Female Male Non-binary Prefer not to say

Age

Under 24 25-34 35-44 45-54 55-64 65-74 75-84 85 and over Prefer not to say

Ethnicity

Do you have any disabilities? (if YES, please tick the box)

Yes No Prefer not to say

Disabilities

Please check the boxes that apply to you:

Vision

Hearing

Mobility

Dexterity

Memory

Mental health

Learning or understanding or concentrating

Stamina or breathing or fatigue

Social or behavioural (ASD)

Other

Further details of your disability

Your feedback

1. Were you ever prevented from sleeping at night from noise?

Yes No N/A

Feedback on question 1

2. Were you able to get a member of staff to help you when you needed assistance?

Feedback on question 2

3. Were you treated with kindness and compassion while you were in hospital?

Yes No N/A

Feedback on question 3

4. Did you get enough help from staff to wash or keep yourself clean?

Yes No N/A

Feedback on question 4

5. Did you get enough help from staff to eat and drink?

Yes No N/A

Feedback on question 5

6. Do you think the hospital staff did everything they could to help control your pain?

Yes No N/A

Feedback on question 6

7. Did staff looking after you involve you in decisions about your care and treatment in a way that you could understand?

Yes No N/A

Feedback on question 7

8. Did you feel able to talk to members of hospital staff about your worries and fears?

Yes No N/A

Feedback on question 8

9. Were you involved in decisions about when you were going to leave hospital?

Yes No N/A

Feedback on question 9

10. Did hospital staff explain the reasons for changing wards during the night?

Yes No N/A

Feedback on question 10

Do you have any other comments?

Please tick this box if you are happy for your feedback to be shared anonymously within our internal communication such as our staff newsletter and internal reports

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