How are you? form

At St Christopher’s we do our best to meet your needs by listening to you, your family and your carers.

One way we do this is by asking you to complete a St Christopher’s questionnaire at regular intervals.

This will help us to focus on what is most important to you.

If you would rather not complete it yourself, then a staff member will be happy to complete the form with you or on your behalf when they see you. The questionnaire is designed to help us understand a number of different issues, such as:

• What is important to you and what your goals are for the next short while
• What, if any, symptoms are affecting you
• How you are managing life at present
• What help you might value, including with any practical issues
• What support your family and friends might need
• How you rate your quality of life at the moment.

If you need help to complete the questionnaire, please do not hesitate to ask one of the team. There are no right and wrong answers – it is purely how you feel.

The information in the questionnaire will be added to your local record and it will be shredded once this is done. For more information on how we use your data view our Privacy Policy or read our leaflet Your information: how we use and keep it.

We hope that you will be able to see that using the questionnaire will enable us to tailor our care and support for you as an individual.

If you are able to, please email the completed form to st.christophers@nhs.net.