Fillable Printable Patient Questionnaire
Fillable Printable Patient Questionnaire
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.
Please mark the box like this
with a ball point pen. If you change your mind just cross out your old response and make your new
choice.
Please write today’s date here:
/
/
1 Are you filling in this questionnaire for:
Yourself
Your child
Your spouse or partner
Another relative or friend
If you are filling this in for someone else, please answer the following questions from the patient’s point of view.
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 an ongoing problem
For treatment (including prescriptions)
Because of a one-off problem
For a routine check
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?
Not very important Very important
1
2
3
4
5
4 How good was your doctor today at each of the following? (Please tick one box in each line)
Poor Less than Satisfactory Good Very Does not
satisfactory good apply
a Being polite
b Making you feel at ease
c Listening to you
d Assessing your medical condition
e Explaining your condition and treatment
f Involving you in decisions about your
treatment
g Providing or arranging treatment for you
3
Patient questionnaire
for Dr
________________________________________________________
5 Please decide how strongly you agree or disagree with the following statements by ticking one box in each line.
Strongly disagree Disagree Neutral Agree Strongly agree Does not apply
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
No
7 I would be completely happy to see this doctor again
Yes
No
8 Was this visit with your usual doctor?
Yes
No
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
12 What is your ethnic group? Please choose one section from A to E, and then tick the appropriate box to indicate your
cultural background.
A White
B Mixed C Asian or Asian British D Black or Black British E Chinese or other ethnic group
British
White and Black
Indian
Caribbean
Chinese
Caribbean
Irish
White and Black
Pakistani
African
Any other
African
Any other white
White and Asian
Bangladeshi
Any other Black
background background
Any other Mixed
Any other Asian
background background
Please write in Please write in Please write in Please write in Please write in
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