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Long Covid Service
Friends & Family Test - Adults
Long Covid Service
Tell us about your visit
Section 1 of 3
* All questions in this section are mandatory
Date of visit / clinic
How did we do?
Section 2 of 3
* All questions in this section are mandatory
Overall, how was your experience of our service?
Select one answer
Very Good
Good
Neither Good Nor Poor
Poor
Very Poor
Don't Know
Were you involved as much as you wanted to be in decisions about your care and treatment?
Select one answer
Yes, definitely
Yes, to some extent
No
Overall. did you feel you were treated with respect and dignity while you were using the service?
Select one answer
Yes, always
Yes, sometimes
No
What worked well?
What could we do better?
Please tick this box if you do not wish to make your comments public
Tell us about yourself
Section 3 of 3
Which of the following options best describes how you think of yourself?
Select one answer
Man (including trans man)
Woman (including trans woman)
Non-binary
In another way
What age band are you in?
Select one answer
0-15
16-19
20-24
25-34
35-44
45-54
55-64
65-74
75-84
85+
Prefer not to say
What is your ethnic group?
Do you have a physical or mental health condition which substantially affects your ability to do normal day to day activities?
Lasting or expected to last 12 months or more
Select one answer
Yes
No
Submit