This Questionnaire is brought to you by Heartlands Patient Forum, we are a group of patients that volunteer our time every 6 weeks to discuss and review our service at Heartlands.

We will endeavour to listen, discuss and review areas of the service you think could be improved and maintaining the service standard whilst the current Trust merger is happening.

In order to review all patients opinions on the service we ask that you complete the questionnaire and return it to us in the box provided. Or complete the form online at

All patients are welcome to come to patient forum meeting, this is our group and our opportunity to have a voice over our service. Posters displaying meeting dates are in reception, or ask a member of staff. You can also email us confidentially on

    As you may be aware, service provision in the National Health Service is constantly changing and evolving. This questionnaire is designed to explore your experience of attending the HIV Clinic at Heartlands Hospital. All responses are anonymous (no individual will be identified), and will be treated as strictly confidential. This is YOUR opportunity to influence the service that you receive.

    Please tick the following that apply to you:-

    1. Gender

    2. I consider my main sexual orientation to be:

    3. Which ethnic group do you identify with? (e.g. Black African, British Asian, White European, etc.) Please specify below:

    4. How many years have been diagnosed as HIV positive?

    5. How easy do you find it to contact the Clinic?
    Very difficultDifficultSlightly DifficultOKNot difficult at all
    Any comment:

    6. How important is it to you that you see the same Consultant at each visit?
    Very importantImportantSlightly ImportantIt doesn't matter to meNot at all important
    Any comment:

    7. How would you rate your relationship with your Consultant?
    Very goodGoodOKNot very satisfactoryNot satisfactory at all
    Any comment:

    8. How would you rate the service provided by the following members of the care team? (If you feel that you have not worked with any particular profession, please leave the appropriate row blank.)

    Medical staff:

    Very goodGoodOKPoorVery Poor

    Clinical nurse specialists:

    Very goodGoodOKPoorVery Poor


    Very goodGoodOKPoorVery Poor

    Sexual Health Nurses:

    Very goodGoodOKPoorVery Poor

    Mental Health Workers (HIV Psychologists):

    Very goodGoodOKPoorVery Poor


    Very goodGoodOKPoorVery Poor

    Reception staff:

    Very goodGoodOKPoorVery Poor

    Others (please specify):

    Very goodGoodOKPoorVery Poor

    Any comment:

    9. In general, how would you rate your visits to the Clinic?
    Above satisfactorySatisfactoryOKNot very satisfactoryNot satisfactory at all
    Any comment:

    10. How would you rate your tailored care plan? (Access to specialist professionals, such as dieticians, etc. when you need them.)
    ExcellentGoodOKNot very satisfactoryNot satisfactory at all
    Any comment:

    11. Have you ever experienced any issues with your medication?
    YesNoNot often
    If yes, please specify:

    12. How do you currently receive your medication?
    Collection from Hospital PharmacyCollection from Local PharmacyHome Delivery

    13. If you needed ongoing support to deal with issues arising from your diagnosis, which of the following would you prefer?
    Health care professional led groupPeer groupOne to one supportOutside agency

    14. Since diagnosis, have you been given information regarding Clinic led support groups?
    YesNoNot sure

    15. Are you aware of the existence of the Patients Forum?
    YesNoNot sure

    16. Do you know what the Patients Forum is/does?
    YesNoNot sure

    17. Would you consider joining the Patients Forum?
    YesNoNot sure

    If you would like further information on the Patient forum, please ask a member of staff or contact us directly at

    Thank you for taking the time to complete this questionnaire, Overall results will be made available when the survey is completed.