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Women's Physiotherapy Pelvic Health patient feedback survey - NHSCT
Page 1 of 3
Closes
31 Jul 2024
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Introduction
1. Age Range
(Required)
16-30 yrs
31-45 yrs
46-60 yrs
61+ yrs
2. Please indicate referral source from list below:
Referral source
(Required)
-- Please Select --
Community midwifery
Consultant
Continence advisor
General practitioner
Health visiting
Hospital
Hospital midwife
Obs and gynae consultant
Physiotherapy
Other professional
If you selected 'other professional', please provide more detail:
There is a limit of 100 characters
3. What are you being treated for?
(Required)
Female Bowel
Female Urinary Incontinence
Pain
Third/Fourth degree tears
Other:
4. Did you receive a physiotherapy pelvic health appointment that you did not attend?
(Required)
Yes
No
5. Please select why you did not attend your appointment?
(Required)
Did not feel comfortable attending the appointment
Menstrual cycle
Forgot about the appointment
No mode of transport
Caring responsibilities
Other
If 'other', please provide additional information:
There is a limit of 500 characters
6. Are you aware that being in the period of your menstrual cycle does not impact your ability to attend a pelvic health appointment?
(Required)
Yes
No
7. Do you have any additional comments or suggestions on how we can improve the physiotherapy pelvic health service for you?
Additional comment:
There is a limit of 500 characters
8. If you would like to be informed of any changes/improvements made to the service as a result of your feedback, please provide your email address below:
Email:
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