Clinic 2 month feedback Survey

You have been sent a link to this survey as you agreed for us to contact you two months after your original clinic appointment to see how you are getting on now. Please fill in the form below and click send - the information is aggregated and used in order to feed back to us and our funders about our services.

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Two Month Post-Clinic Survey

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Name: *

Date of clinic appointment *

1. On a scale (0 to 10), how do you NOW rate your asthma control? ‘0’ is the worst you can imagine and ‘10’ is the best you can imagine. *

2. Have you had better energy levels (Yes/No) *

3. Has your quality of life improved? (Yes/No) *

4. Have you had better exercise tolerance? (Yes/No) *

5. Have you had better nights sleep? (Yes/No) *

6. Have you had less time off work/school? (Yes/No) *

7. Have you had more enjoyment of activities? (Yes/No) *

8. Have you used your reliever (blue) inhaler a) more often b) less often c) Same amount d) Not at all *

9. Since coming to MASH, have you changed the way you manage your asthma? (Yes/No)

If “Yes” what have you changed? *

10. On a scale (0 to 10), how satisfied are you with the service at MASH? ‘0’ is the worst you can imagine and ‘10’ is the best you can imagine. *

Please make any other comments you would like to feedback to us *

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