Name:      Date Of Birth :

Address 1:

Address 2:

Address 3:

Post Code:

Your E-mail Address:

Name of GP:

If you are filling in this form as a family carer or friend of the patient please tell us your name and address or phone number, if different from patient's:-

1. When did you have your stroke? (month and year)

Give date of most recent stroke, if you have had more than one.

2. Were you admitted to hospital? Yes No

IF YES

Which Hospital/s?

Which ward/s?

How long were you there?

Have you any comments about the care you received while in hospital?

3. Did you go home after this or were you transferred elsewhere?

Home

Transferred for rehabilitation to

Other Please specify

4. We would like to know what you thought about the treatment or care you had after your stroke.

What things were good about it?

Were there things you were less happy about?

5. Have you any suggestions for improving the care and treatment of stroke patients?

6. How did your family cope? Would they (or you) have liked more information about stroke – causes, treatment, recovery, what to expect?

IF YES Can you tell us what further information would have been helpful?

7. Is there anything else you would like to add?

Please tick here if you would like information about stroke clubs in your area

IMPORTANT NOTE

 The purpose of this form is to enable us to have your concerns, if any, investigated, and comments, good or bad, passed on to the appropriate people. This means that we may need to share the information you have given us with those involved who work in the stroke service. If, however, you don't want your name divulged please put a cross in this box. We can still take up your comments in a general way, even if you would prefer us not to reveal your name.