PATIENT NEEDS ASSESSMENT

This is a confidential survey to determine areas of interest in programming to better serve the Bleeding Disorder Community. The results will be shared with the Children’s Hospital (CCHMC) and University of Cincinnati’s (AHTC) Treatment Centers and The Tristate Bleeding Disorder Foundation (TSBDF)

(optional)

Name ______________________________  Email________________________  Phone _________________

Address ____________________________________________  City___________  State______  Zip_______

1. Are you a     ___________ patient        or   _____________ family member?

                                               Relationship to patient ______________________

2. _____ Male   _____Female  

3. Are you interested in receiving mail/communications from The Tristate Bleeding Disorder Foundation? 

                   YES     NO                                       

4. Are you interested in men’s programming? Check all that apply

    ____ Retreat ____ Educational _____ Support ____Recreational

    ____ Patients only ____Family members only ____Combination    ____Not interested

5. Are you interested in women’s programming?  Check all that apply

    ____ Retreat ____ Educational _____Support _____Recreational

    ____Patients only _____ Family Members only _____ Combination ____Not interested

6. Are you interested in parenting programs for children with Bleeding Disorders? Check all that apply

   ____ Retreat ____Educational _____Support _____Recreational ____Not interested

   _____________________Age of children                

7. Are you interested in couple’s programming?   Check all that apply

   ____ Retreat _____Educational ____Support _____Recreational

   ____Patients only _____Family members only ____Combination ____Not interested

8. Are you interested in family programming?   Check all that apply

   ____ Retreat ____Educational ____Support ____Recreational

   ____Patients only ____Family Members only ____Combined ____Not interested

9. Are you interested in von Willebrand Disease programming?   Check all that apply

    ____Retreat _____Educational ____Support ____Recreational

    ____Patients only ____Family members only ____Combined ____ Not interested

10. Are you interested in Teen/Young Adult’s programming?  Check all that apply

     _____Retreat _____Educational _____Support _____Recreational

     _____Patients only _____Family members only _____Combined _____Not interested

11. If you have chosen more than one area above (#4 THROUGH #10) please rate your priority area from 1 (Highest) to

     7 (Lowest)

     ______Men’s                           _______Parents                 ______Family             _____Teens/Young Adults

     ______Women’s                      _______Couples              ______vonWillebrands Disease

12. Have you participated in any past programming: CHMC, University and/or Chapter (PLEASE CIRCLE)

     If no, why? ___________________________________________________________________________

Please put a check by all topics you may be interested in:

_____Insurance _____Advocacy _____Dental _____School Issues _____Transitioning ____General Wellness

Other suggestions or comments: _____________________________________________________________

________________________________________________________________________________________