Patient Involvement Network Questionnaire

Question Title

* 1. Contact Information

Name

Address

Address 2

City/Town

Post Code

Email Address

Phone Number

Question Title

* 2. Are you happy to share with us any pre-existing or current disease areas you have been a patient of or participated in a research study within our department?
You do not have to have been a patient or participated in a study to be interested in a research area

	Been a patient of	Participated in a Research Trial	Interested in getting involved in this area
Allergy	Allergy Been a patient of	Allergy Participated in a Research Trial	Allergy Interested in getting involved in this area
Audiology	Audiology Been a patient of	Audiology Participated in a Research Trial	Audiology Interested in getting involved in this area
Cancer	Cancer Been a patient of	Cancer Participated in a Research Trial	Cancer Interested in getting involved in this area
Cardiology	Cardiology Been a patient of	Cardiology Participated in a Research Trial	Cardiology Interested in getting involved in this area
Clinical Genetics	Clinical Genetics Been a patient of	Clinical Genetics Participated in a Research Trial	Clinical Genetics Interested in getting involved in this area
Dental	Dental Been a patient of	Dental Participated in a Research Trial	Dental Interested in getting involved in this area
Dermatology	Dermatology Been a patient of	Dermatology Participated in a Research Trial	Dermatology Interested in getting involved in this area
Diabetes	Diabetes Been a patient of	Diabetes Participated in a Research Trial	Diabetes Interested in getting involved in this area
Ear, Nose & Throat	Ear, Nose & Throat Been a patient of	Ear, Nose & Throat Participated in a Research Trial	Ear, Nose & Throat Interested in getting involved in this area
Emergencies & Critical Care	Emergencies & Critical Care Been a patient of	Emergencies & Critical Care Participated in a Research Trial	Emergencies & Critical Care Interested in getting involved in this area
Gastroenterology	Gastroenterology Been a patient of	Gastroenterology Participated in a Research Trial	Gastroenterology Interested in getting involved in this area
Haematology	Haematology Been a patient of	Haematology Participated in a Research Trial	Haematology Interested in getting involved in this area
Hepatology	Hepatology Been a patient of	Hepatology Participated in a Research Trial	Hepatology Interested in getting involved in this area
HIV	HIV Been a patient of	HIV Participated in a Research Trial	HIV Interested in getting involved in this area
Infection	Infection Been a patient of	Infection Participated in a Research Trial	Infection Interested in getting involved in this area
Lupus	Lupus Been a patient of	Lupus Participated in a Research Trial	Lupus Interested in getting involved in this area
Men's Health	Men's Health Been a patient of	Men's Health Participated in a Research Trial	Men's Health Interested in getting involved in this area
Neurology	Neurology Been a patient of	Neurology Participated in a Research Trial	Neurology Interested in getting involved in this area
None	None Been a patient of	None Participated in a Research Trial	None Interested in getting involved in this area
Nutrition & Dietetics	Nutrition & Dietetics Been a patient of	Nutrition & Dietetics Participated in a Research Trial	Nutrition & Dietetics Interested in getting involved in this area
Ophthalmology	Ophthalmology Been a patient of	Ophthalmology Participated in a Research Trial	Ophthalmology Interested in getting involved in this area
Orthopaedics	Orthopaedics Been a patient of	Orthopaedics Participated in a Research Trial	Orthopaedics Interested in getting involved in this area
Paediatrics	Paediatrics Been a patient of	Paediatrics Participated in a Research Trial	Paediatrics Interested in getting involved in this area
Pain	Pain Been a patient of	Pain Participated in a Research Trial	Pain Interested in getting involved in this area
Palliative Care	Palliative Care Been a patient of	Palliative Care Participated in a Research Trial	Palliative Care Interested in getting involved in this area
Renal	Renal Been a patient of	Renal Participated in a Research Trial	Renal Interested in getting involved in this area
Respiratory	Respiratory Been a patient of	Respiratory Participated in a Research Trial	Respiratory Interested in getting involved in this area
Rheumatology	Rheumatology Been a patient of	Rheumatology Participated in a Research Trial	Rheumatology Interested in getting involved in this area
Sexual & Reproductive Health	Sexual & Reproductive Health Been a patient of	Sexual & Reproductive Health Participated in a Research Trial	Sexual & Reproductive Health Interested in getting involved in this area
Sleep	Sleep Been a patient of	Sleep Participated in a Research Trial	Sleep Interested in getting involved in this area
Surgery	Surgery Been a patient of	Surgery Participated in a Research Trial	Surgery Interested in getting involved in this area
Urology	Urology Been a patient of	Urology Participated in a Research Trial	Urology Interested in getting involved in this area

Others not mentioned

Question Title

* 3. Which of the following Research Areas would you be interested in becoming more involved in if any?

	Please tick all that apply
Genomics / Genetics	Genomics / Genetics Please tick all that apply
Data research & Artificial Intelligence (AI)	Data research & Artificial Intelligence (AI) Please tick all that apply
Cell / Gene therapy	Cell / Gene therapy Please tick all that apply
Social science	Social science Please tick all that apply
Stem cells	Stem cells Please tick all that apply
Imaging e.g. x-rays, CT, MRI	Imaging e.g. x-rays, CT, MRI Please tick all that apply

Patient Involvement Network Questionnaire

Question Title

* 1. Contact Information

Question Title

* 2. Are you happy to share with us any pre-existing or current disease areas you have been a patient of or participated in a research study within our department?You do not have to have been a patient or participated in a study to be interested in a research area

Question Title

* 3. Which of the following Research Areas would you be interested in becoming more involved in if any?

Question Title

* 4. Any Comments / Suggestions/ Feedback:

* 2. Are you happy to share with us any pre-existing or current disease areas you have been a patient of or participated in a research study within our department?
You do not have to have been a patient or participated in a study to be interested in a research area