The Bradford on Avon AND Melksham Health Partner

Young People's Questionnaire

Section 1 - Your Details

How old are you?

12-13

14-15

16-17

18-24

25-30

Are you?

Male

Female

Section 2 - Do You Have a Disability?

If no skip to section three

Learning Disability

Physical Disability

Hearing Problems

Vision Problems

Depression

Other, please state:

Section 3 - Are You a Carer?

If yes, please visit the Carers' section of the website for more information

Yes

No

Section 4 - Your Last Visit To The Surgery

How did you get to the surgery?

Bus

Train

Bicycle

Walk

Car

Did you find it easy to make your appointment?

Yes

No

Was the appointment at the right time for you?

Yes

No

Did you find the staff friendly and welcoming?

Yes

No

Would you encourage your friends to use this surgery?

Yes

No

During your appointment did you feel okay to ask questions about treatment if you were not sure or didn’t understand?

Yes

No

How was your overall experience using the surgery? Rate your experience 1-5 (1 being poor and 5 being excellent)

1

2

3

4

5

Section 5 - Feedback

Did you know we have a young people’s representative at the surgery?

Yes

No

Would a surgery Facebook page be something you would use or be interested in which would be just for young people?

Yes

No

Did you know the surgery had a Patient Voice email group whichenables patients to let us know how we can improve services?

Yes

No

If you would like to be part of the patient voice email group, please provide your email address below:

Are there any other comments you would like to make?