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.

You have recently seen Mr Smith or a member of his team in the outpatient clinic and he would be grateful for some feedback on your experience during the consultation. Please provide as much information as possible and please be assured that anything you write is completly anonymous.

 

Your visit to the clinic:
Date seen
Whom did you see in clinic?
Were you see as
 
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
Which of the following best describes the reason you saw the doctor today?
(please tick all that apply)
To ask for advice Because of an ongoing problem For treatment (inc prescriptions) Because of a one-off problem For a routine check For suspected cancer Other - please specify below
Other:
 
On a scale of 1 to 5, how important to your helath and wellbeing was your reason for visiting the doctor today?
Chooseone: 1 - Not very important
2
3
4
5 - Very important
 
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
The doctor will keep information about me confidential Poor
Less than satisfactory
Satisfactory
Good
Very good
Does not apply
This doctor is honest and trustworthy Poor
Less than satisfactory
Satisfactory
Good
Very good
Does not apply
 
Final questions
I am confident about this doctors ability to provide care Yes No
I would be completely happy to see this doctor again Yes No
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
 
Optional demographic details
Gender Male Female
Age group <15yrs
15-20yrs
21-40yrs
41-60yrs
>60yrs
Ethnic group