Date
Are you filling in this questionnaire for:
YourselfYour childYour spouse or partnerAnother relative or friend
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)
To ask for adviceBecause of an ongoing problemFor treatment (including prescriptions)Because of a one-off problemFor a routine checkOther (please give details)
On a scale of 1 to 5, how important to your health and wellbeing was your reason for visiting the doctor today?
1 (Not very important)2345 (Very important)
How good was your doctor today at each of the following? (Please tick one box in each line)
Being politePoorLess than satisfactorySatisfactoryGoodVery goodDoes not apply
Making you feel at easePoorLess than satisfactorySatisfactoryGoodVery goodDoes not apply
Listening to youPoorLess than satisfactorySatisfactoryGoodVery goodDoes not apply
Assessing your medical conditionPoorLess than satisfactorySatisfactoryGoodVery goodDoes not apply
Explaining your condition and treatment : PoorLess than satisfactorySatisfactoryGoodVery goodDoes not apply
Involving you in decisions about your treatment : PoorLess than satisfactorySatisfactoryGoodVery goodDoes not apply
Providing or arranging treatment for you:PoorLess than satisfactorySatisfactoryGoodVery goodDoes not apply
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 : Strongly disagreeDisagreeNeutralAgreeStrongly agreeDoes not apply
This doctor is honest and trustworthy : Strongly disagreeDisagreeNeutralAgreeStrongly agreeDoes not apply
I am confident about this doctor’s ability to provide care
YESNO
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:
FemaleMale
Age:
Under 1515–2021–4040–6060 or over
What is your ethnic group? Please choose one section from a to e, and then tick the appropriate box to indicate your cultural background.
White
BritishIrishAny other white background
Mixed
White and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed background
Asian or Asian British
IndianPakistaniBangladeshiAny other Asian background
Black or Black British
CaribbeanAfricanAny other Black background
Chinese or other ethnic group
ChineseAny other
