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 do not write your name on this questionnaire. Please base your answers only on the consultation you have had today.

    Are you filling in this questionnaire for:

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

    Which of the following best describes the reason you saw the doctor today? (Please tick all the boxes that apply)

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

    How good was your doctor today at each of the following? (Please tick one box in each line)

    Being polite

    Making you feel at ease

    Listening to you

    Assessing your medical condition

    Explaining your condition and treatment :

    Involving you in decisions about your treatment :

    Providing or arranging treatment for you:

    Please decide how strongly you agree or disagree with the following statements by ticking one box in each line.

    This doctor will keep information about me confidential :

    This doctor is honest and trustworthy :

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

    I would be completely happy to see this doctor again

    Was this visit with your usual doctor?

    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.

    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.

    Are you:


    What is your ethnic group? Please choose one section from a to e, and then tick the appropriate box to indicate your cultural background.