The purpose of collecting this information is to ensure Western Queensland PHN commissioned services meet your health needs and service expectations.

This form is anonymous so please feel comfortable to respond honestly.

How old are you? *

Under 18 years18 to 24 years25 to 44 years45 to 64 years65 years and over

What is your gender Identity? *

MaleFemaleNon-BinaryOtherPrefer not to say

Are you of Aboriginal or Torres Strait Island origin? *

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNo

Other health financial supports (Tick all that apply) *

Private Health Insurance- Hospital coverPrivate Health Insurance- Extras CoverDepartment of VeteransNDIS PackageMy Aged Care PackageNone of the abovePrefer not to say

What is your Country of Birth?

What is your main language spoken at home?

What best describes your current housing situation?

Stable housingI am concerned about maintaining my housingRefuge / temporary accommodationLiving with friends/family temporarilyNo fixed address / homelessPrefer not to say

My feelings about my wellbeing

The World Health Organization-Five Well-Being Index (WHO-5)

Please choose one (1) option for each statement (row) *

All of the time (5)Most of the time (4)More than half of the time (3)Less than half of the time (2)Some of the time (1)At no time (0)

1. I have felt cheerful and in good spirits

All of the time (5)Most of the time (4)More than half of the time (3)Less than half of the time (2)Some of the time (1)At no time (0)

2. I have felt calm and relaxed

All of the time (5)Most of the time (4)More than half of the time (3)Less than half of the time (2)Some of the time (1)At no time (0)

3. I have felt active and vigorous

All of the time (5)Most of the time (4)More than half of the time (3)Less than half of the time (2)Some of the time (1)At no time (0)

4. I woke up feeling fresh and rested

All of the time (5)Most of the time (4)More than half of the time (3)Less than half of the time (2)Some of the time (1)At no time (0)

5. My daily life has been filled with things that interest me

All of the time (5)Most of the time (4)More than half of the time (3)Less than half of the time (2)Some of the time (1)At no time (0)

Please indicate for each of the five statements which is closest to how you have been feeling over the last two weeks. Notice that higher numbers mean better well-being. Example. If you have felt cheerful and in good spirits more than half of the time during the last two weeks, select number three. Example. If you have felt cheerful and in good spirits more than half of the time during the last two weeks, select number three.

© WHO, 2024. License: CC-BY-NC-SA 3.0 IGO

Provider Organisation *

Where were you seen?

How long have you been attending this service? *

1 day to 2 weeks3 to 4 weeks1 to 3 months4 to 6 monthsMore than 6 months

My recent experience

Was your experience with this service? *

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

I did not wait long to get an appointment

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

The service was well organised

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

The facilities were comfortable

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

The service was culturally appropriate

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

The service team member was knowledgeable

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

You must choose 1 option on each line, choose the most accurate statement

How did you feel about the service you received? *

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

I felt safe and respected

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

I felt information was given in way I could understand it

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

I felt I was listened to and involved and in control of my health decisions

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

You must choose 1 option on each line, choose the most accurate statement

My feelings about my health

I feel this service has helped me to... *

Strongly Disagree (0)Disagree (1)Somewhat Disagree (2)Neutral (3)Somewhat Agree (4)Agree (5)Strongly Agree (6)

1. Better manage my condition

Strongly Disagree (0)Disagree (1)Somewhat Disagree (2)Neutral (3)Somewhat Agree (4)Agree (5)Strongly Agree (6)

2. Better manage my overall health and well being

Strongly Disagree (0)Disagree (1)Somewhat Disagree (2)Neutral (3)Somewhat Agree (4)Agree (5)Strongly Agree (6)

3. Feel more positive about my health and well being

Strongly Disagree (0)Disagree (1)Somewhat Disagree (2)Neutral (3)Somewhat Agree (4)Agree (5)Strongly Agree (6)

You must choose 1 option on each line, choose the most accurate statement

The service provided was worthwhile. *

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

The service provided was worthwhile.

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

The service provided supported and improved my quality of life.

Strongly DisagreeDisagreeSomewhat DisagreeNeutralSomewhat AgreeAgreeStrongly Agree

You must choose 1 option on each line, choose the most accurate statement

I would recommend the service to family and friends? *

YesNo

Do you have comments about the service or your experience?

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Template Version:WQPHN-PREOM-2025.08.14.01

Template Type: Template for Completion

Western Queensland PHN

EMT Approved:16.07.2025

Uncontrolled Document when Printed

Health and Wellbeing Service Experience and Outcome Survey

About me

My feelings about my wellbeing

About my provider

My recent experience

My feelings about my health