Patient questionnaire

Thank you for taking the time to complete this questionnaire. All responses are anonymous: you will not be questioned about the answers you give and your doctor will not know how you respond to these questions. All doctors are expected to seek regular feedback from colleagues and patients about their practice. The aim of this is to provide doctors with information about their work through the eyes of their colleagues as well as the patients they treat and to highlight any areas they are performing well in or need to improve in. Below are instructions on how to complete this questionnaire. If you are unable to fill in the form, someone else may complete this on your behalf.

HOW TO FILL IN THIS FORM

  • Please do not write your name on this questionnaire. 
  • Please answer all of the questions that apply to you.
  • If you feel you cannot answer a question, please tick ‘Don’t know’. 
  • Please base your answers solely on the consultation you had today.
  • If you are filling this in for someone else, please answer the questions from the patient’s point of view.

Patient questionnaire

Patient questionnaire

About you (or the patient concerned)

The next 3 questions will provide the doctor with some basic information about you. If you are filling in this questionnaire on behalf of someone else, please provide the following details about them.

About your visit

The following questions will ask you about your visit to the doctor today. If you are fillling in this questionnaire on behalf of someone else, please provide the answers from their point of view.

7. How good was your doctor at the following today? Leave blank if this does not apply.

Poor
Less than satisfactory
Satisfactory
Good
Very Good

8. Please indicate how strongly you agree or disagree with the following statements. Leave blank if this does not apply.

Strongly disagree
Disagree
Neutral
Agree
Strongly Agree