Questionnaire WRHA Program of Genetics and Metabolism

Questionnaire – WRHA Program of Genetics and Metabolism

We are evaluating our clinic sessions in order to improve our services to patients. We would appreciate that you complete this questionnaire with your honest opinions. Please complete and return in the enclosed envelope. We thank you in advance for your time and consideration.

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Please indicate who filled this questionnaire:

( ) male ( ) female ( ) both partners together

Please indicate your age range

( ) 15 – 20 ( ) 41 – 50 ( ) 71 - 80

( ) 21 – 30 ( ) 51 - 60 ( ) 81 - 90

( ) 31 – 40 ( ) 61 - 70 ( ) Other ______

What is the highest grade or level of education you have?

( ) Some high school( ) Some university

( ) Completed high school ( ) Completed university

( ) Some college

( ) Completed college

What is your first language?

( ) English ( ) French ( ) Other: ______

Please choose one of the following:

I am currently ( ) Employed. I work as a ______

( ) Unemployed

( ) At home with children

( ) A student

If applicable,

My partner is currently ( ) Employed. Works as a ______

( ) Unemployed

( ) At home with children

( ) A student

1 (over)

6. Please indicate if the Medical Geneticist/Genetic Counsellor explained:

Yes No Not applicable (N/A)

a) The reason for seeing you in Genetics Clinic
b) That the information discussed would be kept confidential
c) What to expect from the appointment
d) What the conditions being tested for were
e) What were the testing options
f) What the pros and cons of testing were
g) What a normal test result means
h) What an abnormal test result means
i) When to expect test results
j) What the next steps wouldbe

Please check the box that best describes your opinion.

The Medical Geneticist/ Genetic Counsellor I saw:

Agree Disagree Neutral N/A

a) Was knowledgeable in her/his field of expertise
b) Explained things to me in a clear and understandable way
c) Used terminology I did not understand
d) Answered my questions satisfactorily
e) Helped me understand my options and choices
f) Let me make my own decisions in terms of testing
g) Was not supportive of my decision
h) Gave me time to organize my thoughts and ask questions

2 (over)

Did not give me enough time to decide

j) Was sensitive and tactful
k)Treated me with respect at all times
l) Was frequently interrupted during my appointment with him/her

Please check the box that best describes your opinion.

In terms of the clinical environment/setting

Satisfied Dissatisfied Neutral N/A

a) Manner in which I wastreated by the reception staff
b) Amount of time I had to wait to be seen after my designated appointment time
c) Clinic room set up
d) Waiting area set up
e) Parking
f) Wheelchair access to the hospital

Please check the box that best describes your opinion.

Agree Disagree

a) I feel that my appointment in Genetics was a positive experience
b) I would have rather not attended my appointment in Genetics

10. Is there anything that would have made this a more positive experience? Please explain.

The following section is for internal use only.

To be filled in by the WRHA Program of Genetics and Metabolism

Patient seen primarily by: ( ) Medical Geneticist ( ) Genetic Counsellor

Patient was referred for:

( ) General Genetics

( ) Pregnant, abnormal MSS ( ) Pediatric Metabolics

( ) Pregnant, AMA ( ) Adult Metabolics

( ) Pregnant, Other ______( ) HBOC

Patient seen in the:

( ) CSB ( ) CancerCare Manitoba ( ) Women’s OPD

( ) Children’s Clinic ( ) FAU ( ) Other______

( ) Telehealth