Patient Participation Survey

Would you like to have a say about the services provided at Falsgrave Surgery?

Friends of Falsgrave Surgery (FoFS), a new Patient Participation Group, would like to hear your views.

The purpose of the FoFS group is to ensure that patients are involved in decisions about the range and quality of services provided.

By providing your e-mail details we can add them to a contact list that will mean we can contact you by e-mail periodically to ask you a few questions. You can leave the group at any time by sending an e-mail request to stop.

If you don’t have an e-mail address but wish to participate please contact us for further details.

Please download and complete this form and hand back into the surgery by Thursday 20th October 2011, or complete the form online below:

Name:
Email:
Postcode:

Please tick which chronic conditions apply to you:

Diabetes		Hypertension
Heart Disease		Stroke / TIA
Asthma/COPD		Epilepsy
Other

Would you consider your attendance at the surgery as:

Regular (more than 5 times a year)
Occaisonal (1 to 5 times a year)
Very rare (only once a year or less)

To enable us to speak to a representative sample of patients
that are registered at their practice please indicate the following:

Male		Female
Under 16		55 - 64 yrs
17 - 24 yrs		65 - 74 yrs
25 - 34 yrs		75 - 84 yrs
35 - 44 yrs		Over 84
45 - 54 yrs

Ethnic Category:

White
British Group
Irish
Mixed
White & Black Caribbean
White & Black African
White & Asian
Asian or British
Indian
Pakistani
Bangladeshi
Black or Black British
Caribbean
African
Chinese or other Ethnic Group
Chinese
Any Other

Please note that no medical information or questions will be responded to.

The information you supply will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.