032 Programme feedback form

1

Name

First Name

Last Name

2

Service user ID (if known)

3

Which programme are you enrolled on/did you complete?

4

Programme start date (if known)

5

Are you happy for us to use your story for marketing purposes?

YESNO

6

If yes please select all that you are happy for your story to be shared on:

Social media

Xyla Health & Wellbeing website

Case study

I do not want my story to be used for marketing purposes

7

What did you find most useful about your programme?

8

What changes did you make to your lifestyle as a result of attending the programme, e.g. exercise routine, dietary habits?

9

Have you accessed any local services (i.s. leisure centres, exercise on referral) due to this programme?

10

What was your favourite part of the programme and why?

11

What challenges did you face on the programme and how did you overcome them?

12

What changes have you seen in any measurements that have been taken? E.g. weight, waist measurement, clothes size, blood glucose, blood pressure etc.

13

Would you or have you recommended the programme to others? Why?

14

What would you say to those who are thinking of joining the programme?

15

Are there any other comments you wish to make about your experience?

16

Are you happy to share any progress pictures with us? If so please upload them here:

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

17

I agree to my name to be disclosed within marketing materials

YESNO

18

I agree to photos of myself to be used within marketing materials

YESNO

19

I wish to remain anonymous within marketing materials

YESNO

20

SignatureI hereby give permission for my story to be used by Xyla Health & Wellbeing and I consent to this being used for a 12 month period. Should you at any point wish to withdraw this consent you can do so by emailing info@xylahealth.com.

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