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Hello:
You are invited to participate in our survey [Project Description Here]. In this survey, approximately [Approximate Respondents] people will be asked to complete a survey that asks questions about [General Survey Process]. It will take approximately [Approximate Time] minutes to complete the questionnaire.

Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.

Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at the email address specified below.

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.

 
 
 
 
What is your gender?
 
Male
 
Female
 
 
 
What is your marital status?
 
Single (Never married)
 
Married
 
Domestic partnership
 
Widowed
 
Divorced
 
Separated
 
Don’t know
 
 
 
How many children do you have?
 
no children
 
1 child
 
2 children
 
3 children
 
more than 4 children
 
 
 
These next questions are about your use of the health service

In the last 12 months, how many times did you visit a hospital Emergency Department (sometimes called A&E or Accident and Emergency) as a patient??
 
None
 
1 time
 
2
 
3
 
4
 
5 to 9
 
10 or more times
 
Don't know
 
No Reply
 
 
 
In the last 12 months, how many times did you visit a General Practitioner (GP)?
 
None
 
1 time
 
2
 
3
 
4
 
5 to 9
 
10 or more times
 
Don't know
 
No Reply
 
 
 
In the last 12 months, about how many visits did you make to a hospital as an outpatient? (Include all types of consultations, tests, operations, procedures or treatments) ?
 
None
 
1 time
 
2
 
3
 
4
 
5 to 9
 
10 or more times
 
Don't know
 
No Reply
 
 
 
On how many of these visits did you have a substantial procedure, operation or test i.e. one which took a considerable amount of time to perform? Note: These are sometimes called day-case procedures.
 
Weekly
 
Monthly
 
Quarterly
 
Annually
 
 
Here is a list of statements that people have used to describe their lives or how they feel. How often do you feel like this?
often sometimes rarely never
My age prevents me from doing the things I would like to.
I feel that what happens to me is out of my control.
I feel free to plan for the future.
I feel left out of things.
I can do the things that I want to do.
Family responsibilities prevent me from doing what I want to do.
I feel that I can please myself in what I can do.
My health stops me from doing the things I want to do.
Shortage of money stops me from doing the things that I want to do.
I look forward to each day.
often sometimes rarely never
I feel that my life has meaning.
I enjoy the things that I do.
I enjoy being in the company of others.
On balance, I look back on my life with a sense of happiness.
I feel full of energy these days.
I choose to do things that I have never done before.
I feel satisfied with the way my life has turned out.
I feel that life is full of opportunities.
I feel that the future looks good for me.
 
 
The next questions are about how you feel about different
aspects of your life. For each one, please say how often you
feel that way.
Often Some of the time Hardly Ever or Never
How often do you feel you lack companionship?
How often do you feel left out?
How often do you feel isolated from others?
How often do you feel in tune with the people
around you?
How often do you feel lonely?