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
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