We are aware that it’s not unusual after an illness to feel lethargic and unwell especially if the illness has been severe and life threatening.  Sometimes feeling unwell can remain for months, even years but in regards to healthcare infections there is little understanding of the extent of post-infection ill health.

If you do not wish to complete the online questionnaire form but would still like to take part then please download the form here now PDF

The Information provided will be treated in the strictest of confidence.  It will only be held by the nominated Data Controller, in accordance with the Data Protection Act 1998, who in this organisation is the Secretary/Administrator and the information will not be passed to any third party without permission.  Please acknowledge by adding your name here.

This is a list of questions designed to give us as much information as possible, to enable us to give you the most informative advice we can to help support your road to recovery and also provide us with information on how widespread and severe post-infection ill health is. This will enable us to raise awareness of the needs and care of healthcare infection survivors.

Where answers are ‘yes or ‘no’ please circle the right one or cross out the inappropriate one.

Thank you for your time.

Patient details

1.  Male Female    (please circle/or cross out the incorrect answer)

2. What Infection did you contract? 
     (Please enter into the text area)                        
                                                                                       

On What Date?                  How old where you then?

3. Ethnic Group please select                               British white Other white background White/Black Caribbean White/Black African Asian Indian Other

4. Are you the patient or relative?……………     Patient Relative                                                                 

Clinical Details – Pre admission

5. What condition/illness did you/the patient        
     have prior to the infection?                               

6. Were you/the patient  prescribed
     antibiotics prior to admission?                         Yes No

7. Were you/the patient on any other
     immunosuppressive treatment
     (e.g. treatment that you have been
     informed would weaken your immune
     system and lower your resistance to
     infection)?                                                           Yes No

8. Do you/the patient believe your
    immunity was low the week prior to this
    infection (e.g. were you recovering from
    another infection or illness?
    If YES, please give details.                                Yes No

                                                                  Details:  

Questions on Admission

9. What were hygiene compliance
    standards on your ward?                                    Enviromental

                                                                                  Hand Hygiene

10. Where you/the patient given
      any information once the infection
      was diagnosed?                                                Yes No

11.  What infection control measures
        were used:                                                       Barrier Nursing Isolation Other
        Please state them if not in the list.                                                                        

12. Were you/the patient visited by
       the infection control team?                              Yes No

13. How long was your/the patient’s
      stay in hospital?         (Days/Weeks/Months)                                                                                                                                    

14. Did anyone discuss with you
      the patient the after care when leaving
      the hospital?                                                      Yes No

 Discharge

15. How long ago did you/the patient
      leave the hospital?                                           

16. How did you/the patient feel?                         

17. can you/the patient describe
       how they are feeling now, what
       are the current symptoms?                             

18. What impact is this having on
       your/the patients life?

19. How has your illness affected family
      or friends in anyway – eg time out of
      work to care, financial difficulties, long
      distance travelling, health etc?
                                                                                 

20. Have the symptoms improved
      or become worse?                                            Improved Worse

21. Has it affected your/the patients
       eating habits?                                                   Yes No

22. Has anyone informed you/the
      patient about nutrition?                                     Yes No

23. Please add anything here that
       you feel might be of any relevance.
                                                                                   

24. How did you hear about NCHI?                       Television Radio Newspaper Magazine Leaflet Word of mouth                                                                                                          

Thank you for completing this form and we do apologise if these questions have upset you. But every answer will be extremely useful.

Please return to:
NCHI
10 Smiths Lane
Hindley Green
Wigan WN2 4XR