Healthier You/XYLA Programme feedback form

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Full Name* This field is required.
First Name
Last Name
2
Service user ID (if known)Optional
3
Which programme are you enrolled on/did you complete?* This field is required.
4
Which programme are you enrolled on/did you complete?* This field is required.
NHS Diabetes Prevention Programme
NHS Behavioural Support for Obesity Prescribing Programme
NHS Long Term Conditions Prevention Programme
5
How would you describe your ethnicity?Optional
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Please select your location* This field is required.
Please Select
Please Select
Bath, Swindon & Wiltshire
Bedford, Luton & Milton Keynes
Coventry & Warwickshire
Devon
Frimley
Gloucestershire
Hampshire & Isle of Wight
Humber & North Yorkshire
Lincolnshire
Leicester, Leicestershire & Rutland
Mid & South Essex
Norfolk & Waveney
Somerset
Suffolk & North East Essex
Sussex
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Age RangeOptional
Please Select
Please Select
18-40
41-65
66-80
80+
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Which programme pathway are you enrolled on/ did you complete?* This field is required.
Please Select
Please Select
NDPP Face-to- Face Group
NDPP Tailored Remote Service- Online Group: History of Gestational Diabetes
NDPP Tailored Remote Service- Online Group: Language
NDPP Tailored Remote Service- Online Group: Visual or Hearing Impairment
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Programme start date (if known)
10
Are you happy for us to use your story for marketing purposes?* This field is required.
YESNO
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If yes please select all that you are happy for your story to be shared on:* This field is required.
Social media
Xyla Health & Wellbeing website
Case study
I do not want my story to be used for marketing purposes
12
Your journey: What did you find most useful about the programme/sessions?
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13
What changes did you make to your lifestyle as a result of attending the programme, e.g. exercise, dietary habits?
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14
Have you accessed any local services (i.s. leisure centres, exercise on referral) due to this programme?
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What was your favourite part of the programme and why?
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What challenges did you face on the programme and how did you overcome them?
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Have you seen in any changes in measurements that have been taken? E.g. HbA1c blood glucose, weight, waist measurement, clothes size, blood pressure etc. Any other changes your have noticed? E.g. Better mood, more energy.* This field is required.
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Would you or have you recommended the programme to others? What would you say to those who are thinking of joining the programme?
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What would you say to those who are thinking of joining the programme?
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Are there any other comments you wish to make about your experience?
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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
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Would you consent to us contacting you regarding the opportunity to promote the programme e.g. radio, television or local health events?* This field is required.
YESNO
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Would you consent to us contacting you for further information? e.g. by phone call or email
YESNO
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Would you consent to us contacting you to collect further information?* This field is required.
NO
Yes, via telephone
Yes, via email
Yes via email or telephone
25
I agree to my first name being disclosed within marketing materials* This field is required.
YESNO
26
I agree to photos of myself to be used within marketing materials
YESNO
27
I wish to remain anonymous within marketing materials
YESNO
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Signature* This field is required.I 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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