Patient Feedback Form

Patient Questionnaire

Licensed doctors are expected to seek feedback from colleagues and patients and review and act upon that feedback where appropriate.

The purpose of this exercise is to provide doctors with information about their work through the eyes of those they work with and treat, and is intended to help inform their further development.

Please base your answers only on your most recent consultation.

If you are filling this in for someone else, please answer the following questions from the patient’s point of view.

If you would prefer a printable version of the patient questionnaire, please use the button below.

Printable Feedback Form

Online Patient Questionnaire

1. Are you filling in this questionnaire for:

Yourself

Your child

Your spouse or partner

Another relative or friend

2. Which of the following best describes the reason you saw the doctor today?

To ask for advice

Because of an ongoing problem

For treatment (including prescriptions)

Because of a one-off problem

For a routine check

Other

2a. If you answered "Other" above, please give details

3. On a scale of 1 to 5, how important to your health and wellbeing was your reason for visiting the doctor today?

4. How good was your doctor today at each of the following?

e. Explaining your condition and treatment

f. Involving you in decisions about your treatment

g. Providing or arranging treatment for you

5. Please decide how strongly you agree or disagree with the following statements

a. This doctor will keep information about me confidential

b. This doctor is honest and trustworthy

6. I am confident about this doctor’s ability to provide care

Yes

7. I would be completely happy to see this doctor again

Yes

8. Was this visit with your usual doctor?

Yes

9. Please add any other comments you want to make about this doctor. Please note: No patients will be identified when this information is given to the doctor.

Free Text

The next questions will provide the doctor with some basic information about who took part in the survey. If you are filling this

in on behalf of a child or a patient with a disability, please provide details about the patient.

10. Are you:

Male

Female

12. What is your ethnic group?

12a. If you answered "Other" please specify

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