Patient questionnaire
Patient Feedback Questionnaire
Welcome to our Patient Feedback Questionnaire! This survey is designed to gather valuable insights about your recent experience with your doctor. Your feedback is crucial in helping healthcare providers enhance their services and patient care.
- Participate anonymously
- Contribute to better healthcare
- Share your thoughts on your doctor’s performance
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
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
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? (Please tick all the boxes that apply)
To ask for advice
Because of a one-off problem
Because of an ongoing problem
For a routine check
For treatment (including prescriptions)
Other (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?
1 Not very important
2
3
4
5 Very important
4 How good was your doctor today at each of the following? (Please tick one box in each line)
4 How good was your doctor today at each of the following? (Please tick one box in each line)
Explaining your condition and treatment
Poor
Less than Satisfactory
Satisfactory
Good
Very good
Does not apply
Involving you in decisions about your treatment
Poor
Less than Satisfactory
Satisfactory
Good
Very good
Does not apply
Providing or arranging treatment for you
Poor
Less than Satisfactory
Satisfactory
Good
Very good
Does 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 disagree
Disagree
Neutral
Agree
Strongly agree
Does not apply
This doctor is honest and trustworthy
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Does not apply
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
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.
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.
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