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Patient questionnaire

A healthcare setting with a patient discussing with a doctor, a friendly and professional atmosphere, warm colors, emphasizing communication and trust

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

24 Questions6 MinutesCreated by CaringPatient123

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

Date:

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

5 Very important

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

Being polite

Poor

Less than Satisfactory

Satisfactory

Good

Very good

Does not apply

Making you feel at ease

Poor

Less than Satisfactory

Satisfactory

Good

Very good

Does not apply

Listening to you

Poor

Less than Satisfactory

Satisfactory

Good

Very good

Does not apply

Assessing your medical condition

Poor

Less than Satisfactory

Satisfactory

Good

Very good

Does not apply

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

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

Yes

I would be completely happy to see this doctor again

Yes

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

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:

Female

Male

11 Age:

Under 15

15–20

21–40

40–60

60 or over

What is your ethnic group? Please choose one section

White

Mixed

Asian or Asian British

Black or Black British

Chinese or other ethnic group

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