S-Word Rotherham Questionnaire

	LET'S TALK ABOUT SEX :: OUR CLINICS & SERVICES

1	Please tell us where you completed the questionnaire?

2a	Have you heard of any of following places in the Rotherham area where you can get information about sexual health and contraception? (Please tick relevant box[es])
	Youth Start/Youth Clinics Central Contraception and Sexual Health Clinic Genito-Urinary Medicine (GUM) Clinic Local GPs Pharmacist/chemist

2b	Have you ever visited any of the above services?
	Please tell us which:

2c	From the sexual health services listed above and any others you know of or have used, which have worked well for you and which have not? (Please write in the boxes below)
	Worked well:

	Not worked well:

2d	Thinking about the service you used most recently, were you offered an appointment/or seen within:

	Name of service:

2e	Please write any comments about the service in the box below:

3	When looking for help or support about sexual health and contraception where would you prefer to go? (Please select one only)
	GP surgery Local service in a health centre Local service in a youth club (young people only) Hospital based service Specialist service in town e.g. Contraception and Sexual Health Clinic Combined service e.g., Contraception and Sexual Health services and Genito-Urinary Medicine (GUM) services in the same location

4	When you go for advice on sexual health and contraception which of the following is the most important?

	If 'other' please specify:

Please can you give us some information about you.
We do not need your name.

5	Age:

6	I am:
	Male Female

7	What area of Rotherham do you live in?

8	Which ethnic group do you belong to?

	If 'other' please specify:

9	(Optional question) Please state your sexuality:
	Heterosexual Bisexual Gay Lesbian

10	(Optional question) We may want to talk to some people about their experience of services and how to make them better. If you would be willing to talk to us further please write your name and contact details below.
	Name:

	Address:

	Telephone number:

All information will be kept strictly confidential and anonymous.

Send off your completed questionnaire

www.s-wordrotherham.co.uk