Feedback about your experience

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We are very keen to continuously improve the service we provide to our clients. Your views about this are very important to us and will be treated in the strictest confidence. We will not ask your name or other information that can identify you. Please answer the following questions as honestly as you can.

Which borough did you access the service in:
*

Please state the month you had your first appointment with the service: *

Overall, how was your experience of our service? Please tick one
*

Very good

Good

Neither good nor poor

Poor

Very poor

Don't know

Please can you tell us why you gave your answer?

Was it easy to contact Breathe?
*

Yes

Were you offered a range of options of support to choose from? E.g. support by telephone, face to face appointments, Nicotine Replacement Therapy (patches, gum etc.) sent by post.
*

Yes

Which support did you choose?
*

A few sessions of face to face appointments, followed by telephone support

Telephone support, with the option of receiving Nicotine Replacement Therapy in the post

Several face to face appointments with the advisor over a period longer than a month

Other:

Did you find the service flexible and convenient to access?
*

Yes

Unsure

Were you offered a choice of medication?
*

Yes

Was it helpful having your carbon monoxide (CO) reading done?
*

Yes

I did not have a CO reading

Did you stop smoking?
*

Yes

Would you recommend our service to your family/friends?
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Yes

Unsure

If you started smoking again would you return to the service for help to stop?
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Yes

Unsure

How did you hear about Breathe Stop Smoking Service?
*

Breathe website or social media (Facebook & Twitter)

Marketing materials (postcards, leaflets & posters)

Outreach team (community event / Breathe van)

Family or friend

GP / Pharmacy / Other healthcare professional

Used service before

Other:

This survey is anonymous but if you would like to leave your contact details, please do so below:

Yes

Clear selection

Name (optional):

E-mail/Tel (optional)

My ethnicity:

Black/African/Caribbean/Black British

Asian/Asian British

Mixed/Multiple ethnic groups

Other ethnic group

White

Prefer not to say

Clear selection

My gender:

Male

Female

I use another term e.g. Non Binary

Prefer not to say

Other:

Clear selection

Do you consider yourself to be trans?

Yes

Prefer not to say

Clear selection

My age:

0-15

16-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

Prefer not to say

Clear selection

Sexual Orientation:

Heterosexual/straight

Lesbian/Gay

Prefer not to say

I use another term

Other:

Clear selection

Religion or Beliefs:

No religion

Christian (including Church of England, Catholic, Protestant and all other Christian denominations)

Buddhist

Hindu

Jewish

Muslim

Sikh

Prefer not to say

Other:

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Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? (include any issues/problems related to old age)

Yes, limited a lot

Yes, limited a little

Prefer not to say

Clear selection

Are you pregnant or have you given birth in the last 26 weeks?

Yes

Prefer not to say

Clear selection

Please tick this box if you do not wish your comments to be made public

Do not wish comments to be made public

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