When were you in hospital, attending a clinic or visiting your GP?

Which hospital, clinic or surgery was it?

What were you there for? e.g Emergency treatment, a planned admission to hospital, Physiotherapy, Occupational Therapy, repeat Prescription.

If you had a stay in hospital, what needed to be arranged for you to leave hospital?

Were you asked for your views on your requirements and were you happy with the arrangements?
Please choose: Yes No

If no, what were the difficulties you had?

Have you had to be re-admitted to hospital, after discharge?
Please choose: Yes No

If yes, why was this?

While in hospital or being treated, did you feel that you were treated with respect and dignity at all times?
Please choose: Yes No

If not, please tell us about it.

Do you think your age made any difference to the treatment you received in any way?
Please choose: Yes No

If so, please tell us about it here:

Do you think that anything could have been improved?

Is there anything else about your experience with the NHS you would like to tell us about?

What specific part/department of the hospital is your complaint against?

If the treatment you received while in or attending hospital was to your satisfaction please state what part/department of the hospital this was?

We will share your real life experience to inform the NHS how its services to older people could be improved.

Your name, address and telephone number will be kept confidential unless you advise us below.

Name:   

Address:

Telephone number:

E-mail address:      

What age are you:
       50 - 60
       60 - 70
       70 - 80
          80 +

Please return this form to AGE CONCERN ESSEX, 112 Springfield Road, Chelmsford, CM2 6LF. Tel. 01245 346106 Fax 01245 346107.
You can also get help at this address. if you need it, with completing this form

I give permission for AGE CONCERN ESSEX to give my name, address and telephone number to a third party.
Please choose: Yes No