About Your Experience Share Your Experience "*" indicates required fields 1Reason For Contact2Your Details3About Your Experience4Demographics5Demographics6Privacy Statement What is the reason you are contacting Healthwatch? To give feedback about a Health and Social Care service To ask for information or advice Please tell us more: If you want to be contacted about your experience, please enter your details below:Name Prefix DrMissMrMrsMsProf.Rev. First Last PhoneEmail Would you be interested in signing up to the Healthwatch Newsletter where you can find out more information about what we and others are doing to improve your local services? Yes No Would you be interested in finding out more about Healthwatch Volunteering opportunities? Yes No Are you:*The PatientThe Parent of the PatientThe Relative of the PatientThe Friend of the PatientThe Carer of the PatientA Staff Member of the ServiceOtherWhich services is your experience regarding?* Castle Hill Hospital Care Home Children and Young Person's Service City Health Care Partnership Day Services Dentist GP Surgery Home Care Hull Clinical Commissioning Group Hull Royal Infirmary Local Authority Mental Health Services NHS 111 NHS Humber Foundation Trust NHS Humber Learning Disability Opticians Pharmacist Sexual Health Services Track and Trace Voluntary and Community Sector Group Yorkshire Ambulance Service Other Please choose the department or wardAdult Social Care Discharge SuiteArtificial Limb UnitAudiology OutpatientsBereavement ServicesBowel ScreeningBreast Care Unit CHHCardiac Day WardCardiac Monitoring Unit (CMU)Cardiac OutpatientsCardiology 5-Day WardCardiothoracic SurgeryCT and MRI SuiteCICU1CICU2 and 3Day Surgery Unit 3Day Surgery Unit (Daisy Building)Dermatology Minor TheatresDermatology OutpatientsDisability Medicine and RehabilitationEndoscopy UnitEndoscopy Satellite UnitECG TestingENT and Audiology DepartmentGI PhysiologyHaematology OutpatientsHull Adult Cystic Fibrosis CentreHaemophiliaHumberside Breast Screening ServiceImmunology and AllergyImmunology OutpatientsJack Brignall (Hull) PET-CT CentreLung FunctionLymphedemaMacmillan Chemotherapy Nurse SpecialistsMain Outpatient DepartmentMain ReceptionMaxillofacial OutpatientsMill View CourtNeurosurgery OutpatientsOncology and NeurosurgeryOncologyOPAT ClinicPalliative CarePatient Advice and Liaison ServicesPharmacyPhysiotherapy and Occupational TherapyPlastic Surgery OutpatientsPre-assessmentQueen's CentreQueen's Centre Day Treatment UnitQueen's Centre OutpatientsQueen's Centre PharmacyRadiologyRadiotherapyStorma Care (Poppy Suite)Surgical Admissions Lounge (SAL)Teenage and Young Adults Unit (TYAC)Teenage Cancer UnitTherapy CentreUltrasoundUrology Ambulatory UnitUrology Day ServicesWard 3Ward 4Ward 7Ward 9Ward 10Ward 11Ward 12Ward 13Ward 14Ward 15Ward 16Ward 19Ward 21Ward 26Ward 27Ward 28Ward 29Ward 30Ward 31Ward 32Ward 33Westwood SuitePlease select the name of the care home35 Priory GroveAlderson HouseAlexander CourtAsh LodgeBeech Lawn Care HomeBerkeley House Care HomeBeverley Court Residential HomeBridlington HouseCastle KeepCastle ParkCastle RiseChurchill HouseCIC - Sunshine HouseCottingham HallDales HouseCountry CourtDesmond House LimitedDurham Care HomesEastfield Residential HomeEbor LodgeElm Tree CourtFern LeaHadley Place Residential HomeHamshaw CourtHaworth Court Residential Home LTDHighfield Resource CentreHolderness HouseHoly Name Care HomeIvanhoeKesteven Grange Care HomeLake View ManorLonghill HouseLoran HouseMaybury CourtMurrayfield Care CentrePark ViewPearson Park Care HomePriory Grange Care Home LTDQueensgate Residential HomeRaleigh CourtRiverbankRockcliffe CourtRose Villa Nursing HomeRossmoreSaltshouse HavenSomerville HouseSt Andrews CourtSt Clare HouseSt Marys Nursing HomeSunningdaleSutton House Nursing HomeSutton Village Care HomeSycamore HouseThe ElmsThe Pennine CentreVictory Social Care EnterpriseWestdene Residential HomeWest Park Residential HomeWilton LodgePlease select the name of the dental practice543 Dental Centre LTDAndrew BurnellAyer Dental SurgeryC Langley Dental SurgeryCDS City Health DentalCHCP CICCity Health DentalDr A MohaghDr B WilsonMr BR DaviesDr D BoffDr FC HeylingsDr N AlldayFreetown Way PracticeGensis Dental CareGenix Healthcare HullGriffin Dental PracticeIDH MarfleetManor Dental HealthMydentist – Hessle High RoadMydentist – Holderness RoadMydentist – NewlandNight Dental LimitedOasis Dental Care LTDSutton Dental PracticeThe Dental Design StudioThe Lund Dental PracticeThe White House Dental PracticeTotal OrthodonticsTrenton Dental PracticePlease select the name of the GP practiceAlexandra Health CentreBransholme South Health CentreBridge Group Practice (Within Elliot Chappell)Burnbrae SurgeryCalvert Medical CentreClifton House Medical CentreDelta Healthcare (Park Health Centre)Diadem Medical Practice (Bilton Grange Health Centre)Dr Cook BFDr GT HendrowDr K V GopalDr Raut Partnership (Branch)Dr Raut Partnership (Within Highlands Health Centre)East Hull Family PracticeEast Hull Family Practice (Morrill Street Health Centre)East Hull Family Practice (Park Health Centre)East Park Practice (Park Health Centre)Faith House SurgeryFieldview SurgeryGoodheart Surgery (Within Bransholme Health Centre)Hastings Medical CentreHaxby Kingswood SurgeryHaxby Orchard Park SurgeryJames Alexander Family Practice (Within Bransholme Health Centre)Kingston Health (Park Health Centre)Kingston Health (Wheeler Street)Laurbel SurgeryMarfleet Group PracticeNew Hall SurgeryNewington SurgeryNewland Group Medical PracticeNewland Health CentreNorthpoint Medical Practice (Within Bransholme Health Centre)Oaks Medical CentreOrchard 2000 Medical CentrePrinces Medical CentreRiverside Medical CentreSouthcoates Medical CentreSpringhead Medical CentreSt Andrews Group Practice (Within Elliot Chappell)St Andrews Group Practice (Within Newington)Sutton Manor SurgerySydenham Group Practice (Within Elliot Chappell)The Avenues Medical CentreThe Quays Medical PracticeWilberforce SurgeryWolseley Medical CentrePlease select the name of the home care serviceAdvanced CareAvocet Trust Domiciliary CareBluebird Care (Hull and Beverley)BurlingtonCaremarkCecil GardensEast Riding of Yorkshire in the Home ServiceGrove HouseHCHA Care ServicesHICA HomecareHIL Care (East Yorkshire) LimitedHumbercare Ltd Hull OfficeKingston-Upon-Hull City Council - Supporting Independence TeamRedwood GladesSpringfield HealthcareRoyal Mencap Society - Hull Domiciliary Care AgencySure HomecareSwanton Community CareVictory Social CareWellington Care Head OfficeWestwood Care and Support Services Yorkshire LtdWhite House Home Care Services LimitedWilberforce HealthcareWishes Care and Support YorkshireYour LivesPlease choose the department or wardAAA Screening (Abdominal Aortic Aneurysm)Acorn WardAcute Assessment UnitAmbulatory Care UnitAntenatal ScreeningAntenatal OutpatientsAudiology OutpatientsBereavement and Mortuary ServicesBone DensitometryBreast Screening OutpatientsCellular PathologyChaplainsChest ClinicChildren's Accident and EmergencyCT and Ultrasound ScanningChildren's OutpatientsDay Surgery UnitDelivery SuiteDiabetes CentreDiabetic Eye ScreeningDischarge LoungeEarly Pregnancy Assessment UnitECG ClinicElderly Assessment Unit (Ward 200)Elderly Short Stay UnitEmergency Care AreaEmergency DepartmentEmergency Gynaecology UnitENT OutpatientsEye ClinicFatima Allam Birth Centre (MLU)Fracture Clinic (Adults)Fracture Clinic (Children)GI Endoscopy UnitGynaecologyGynaecology OutpatientsHICU1HICU2Hull Maternity ServicesHull Major Trauma CentreHull NHS Dialysis UnitHysteroscopy ServiceInitial AssessmentIVF UnitLabour WardLiaison PsychiatryMaple WardMedical Day UnitMedical OutpatientsMRI CentreNeonatal Intensive Care UnitNeuropathologyNeurophysiologyNutrition and DieteticsOccupational TherapyOperating TheatresOncology and NeurosurgeryOphthalmology Day CaseOphthalmology OutpatientsOphthalmology Pre-Operation AssessmentOrthopaedic OutpatientsPatient TransportPaediatricsPaediatric Assessment UnitPaediatric High Dependancy UnitPallative Care (Macmilan)PharmacyPhysiotherapyPlastic Trauma and Surgical OutpatientsPlastics Trauma ClinicPregnancy Advisory ServiceRadiologyRadiotherapyResusRowan WardSpeech and Language TherapySurgical OutpatientsTherapies CentreVascular DepartmentWard 1Ward 4Ward 5Ward 6Ward 7Ward 8Ward 9Ward 10Ward 11Ward 12Ward 30Ward 31Ward 32Ward 33Ward 34Ward 35Ward 36Ward 37Ward 38Ward 40Ward 50Ward 60Ward 70Ward 80Ward 90Ward 100Ward 110Ward 120Ward 130Ward 500Please select the name of the opticians serviceAsda Opticians - BiltonAsda Opticians – Hessle RoadAsda Opticians - KingswoodAsda Opticians – Mount PleasantBlair OpticiansBright EyesBuckingham OpticiansBush Opticians (Hull) LTDDaniels Turner and AssociatesJane Gray Eyecare LtdM & A OpticsOptical ExpressR M HigsonRobert Higson Opticians – Holderness RoadRouse Opticians – Hessle RoadRose Eyecare LTDRouse Opticians – Newland AvenueRouse Opticians – North PointSpecsavers Opticians – Jameson StreetTesco Opticians – Park StreetThe Spectacle ShopTodd & ClarkeValli & Berriman OpticiansVision Express (UK) Ltd – St StephensVision Plus OpticiansWheatcroft Opticians LTD – North PointWheatcroft Opticians LTD – Spring BankWinter OpticiansPlease select the name of the pharmacyAsda Pharmacy – Hessle RoadAsda Pharmacy – Mount PleasantBoots – Askew AvenueBoots – 153 Beverley RoadBoots – 232 Beverley RoadBoots – 860 Beverley RoadBoots – Chanterlands AvenueBoots – Church StreetBoots – Greenwood AvenueBoots – 218 Hessle RoadBoots – 763 Hessle RoadBoots – 250 Holderness RoadBoots – 300 Holderness RoadBoots – 464 Holderness RoadBoots – Kingston Retail ParkBoots – Ings CentreBoots – Londesbourgh StreetBoots – Newland AvenueBoots – North PointBoots – Spring Bank WestBoots – St StephensBrocklehurst Chemists - Hotham RoadBrocklehurst Chemists - Willerby RoadCity Health Pharmacy – Walker StreetCity Health Pharmacy – Victoria DockDay Lewis PharmacyFf and R StevensonJe Mackenzie – Chanterlands AvenueJe Mackenzie – Anlaby RoadJhoots PharmacyKeith’s Pharmacy LimitedKingston Pharmacy - Anlaby RoadKingston Pharmacy - Holderness RoadLate Night PharmacyLincolnshire Co-Op ChemistsLloydspharmacy – Anlaby RoadLloydspharmacy – Goodhart RoadLloydspharmacy – Marfleet LaneLloydspharmacy – Morrill StreetLloydspharmacy – Preston RoadLloydspharmacy – Southcoates LaneLloydspharmacy – Sutton ParkMorrill PharmacyMorrisons PharmacyNewington PharmacyNewland Community Pharmacy LTDNewtons PharmacyOrchard 2000 PharmacyRaymond C HallSuperdrug PharmacySutton Manor PharmacyTesco – St StephensWell – Hull – Princes AvenueWell – Hull – Holderness RoadWhitworth Chemists LTDWilberforce PharmacyIf known, what is the name of the service or department? When did this experience occur?*If exact date is not known, please select any date within the month the experience occurred. DD slash MM slash YYYY Was this experience due to COVID-19?* Yes No What is your experience?* Would you be happy with completing anonymous demographic questions which would help us understand our local community better?* Yes No What is your postcode?HU1HU2HU3HU4HU5HU6HU7HU8HU9I'd prefer not to sayNot knownWhat is your age?0 - 1212 - 1617 - 2425 - 3435 - 4445 - 5464 - 7980+I'd prefer not to sayNot knownWhat is your ethnic background?ArabAsian / Asian British: BangladeshiAsian / Asian British: ChineseAsian / Asian British: IndianAsian / Asian British: PakistaniAsian / Asian British: Any other Asian / Asian British backgroundBlack / Black British: AfricanBlack / Black British: CaribbeanBlack / Black British: Any other Black / Black British backgroundMixed / Multiple ethnic groups: Asian and WhiteMixed / Multiple ethnic groups: Black African and WhiteMixed / Multiple ethnic groups: Black Caribbean and WhiteMixed / Multiple ethnic groups: Any other Mixed / Multiple ethnic backgroundWhite: British / English / Northern Irish / Scottish / WelshWhite: Gypsy, Traveller or Irish TravellerWhite: IrishWhite: RomaWhite: Any other White backgroundAnother ethnic backgroundI’d prefer not to sayNot knownWhat is your gender identity?ManWomanNon-binaryIntersexPrefer not to sayNot knownIs your gender identity the same as the sex assigned at birth?YesNoPrefer not to sayNot knownWhat is your sexual orientation?SingleIn a relationshipCohabitingMarriedSeparatedDivorced / Dissolved Civil PartnershipWidowedPrefer not to sayNot knownDo you have a religion or belief?BuddhistChristianHinduJewishMuslimSikhNo religionPrefer not to sayNot knownWhat is your pregnancy / maternity status? Currently pregnant Currently breastfeeding Given birth in the last 26 weeks Prefer not to say Not known Not applicable Do you have a disability?YesNoPrefer not to sayNot knownWhat type of disability or disabilities do you have? Physical or mobility impairment Sensory impairment Learning disability or difficulties Mental health condition Long term condition Other Do you have a long term health condition?YesNoPrefer not to sayNot knownWhat type of long term health condition do you have? Asthma, COPD or respiratory condition Blindness or severe visual impairment Cancer Cardiovascular condition (including stroke) Chronic kidney disease Deafness or severe hearing impairment Dementia Diabetes Epilepsy Hypertension Learning disability Mental health condition Musculoskeletal condition Other Consent*Your views will be treated confidentially and anonymously. We will use the information you provide to help us look at the quality of local health and social care services. We will produce summary reports of all the views we receive, which we may sometimes share with other public bodies to assist them in performing their own duty to improve local services. We will not share your personal information without your permission. All information will be handled and shared in accordance with the General Data Protection Regulation (GDPR) 2018. We will take all necessary steps to ensure that your information is treated securely. I agree to the privacy policy.HiddenOnce you submit this form you will need to contact us further if you want to provide more information. Are you happy with your responses? Yes No CAPTCHA
