Patient Questionnaire

Email Address *

1. Where did you have your appointment?

(Please select your local area)

Stockport

Heywood, Middleton & Rochdale

Manchester

Tameside & Glossop

Wigan

Bolton

Bury

2. Service

(Please select the service delivered)

Cataract

Minor Eye Conditions Service

Glaucoma Repeat Measures

Enhance Sight for Learning Disabilities

3. How likely are you to recommend this service to friends and family if they needed similar care or treatment?

(Please select the most appropriate response)

Extremely Likely

Likely

Neither Likely or Unlikely

Unlikely

Extremely Unlikely

4. Do you have any comments about the service you received?

5. Do you have a long-standing illness or disability?

Yes

No

Do not want to say

Deaf / hard of hearing

Blind visual impairment

Learning disability

Long-term condition

6. As a woman, are you a pregnant, on maternity leave or returning from maternity leave?

Yes

No

Do not wish to say

7. What is your ethnic background?

WHITE

British

Irish

Other

BLACK

African

Caribbean

Other

MIXED RACE

White & Black African

White & Black Caribbean

White & Asian

Other

ASIAN

Indian

Pakistani

Bangladeshi

Other

OTHER BACKGROUND

Gypsy / Traveller

Chinese

Other

7. What is your religion or belief?

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

None

Other

8. THIS SECTION TO BE COMPLETED BY OVER 16s ONLY What is your sexual orientation?

Heterosexual / straight

Homosexual / gay man

Lesbian / gay woman

Bisexual

Do not wish to say

9. Is your gender the same as you were assigned at birth?

Yes

No

10. What is your marital status?

Single

Legally separated

Cohabiting

Divorced

Married

Widowed

In a civil partnership