The document is a patient questionnaire for healthcare practitioners to receive feedback on their work. It asks patients questions about their reason for visiting, how important their health issue was, how good the practitioner was at various tasks like listening and explaining treatment, whether the patient is confident in the practitioner and would see them again. It collects some basic demographic information and was adapted from a GMC patient questionnaire to provide practitioners information to help inform their further development.

1. Patient questionnaire for (staff name): __________________________ Today’s date: ____/____ /________
Healthcare practitioners 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 healthcare practitioners with information about their work through the
eyes of those they work with and treat and is intended to help inform their further development.
Do not write your name on this questionnaire and base your answers on the consultation you have had today.
1 Are you completing this questionnaire for;
Yourself Your spouse or partner Another relative or friend
If you are completing this for someone else, answer the following questions from the patient’s point of view.
2 Which of the following best describes the reason you saw the practitioner today?
To ask for advice An ongoing problem For treatment
A one-off problem A routine check Other (details below)
__________________________________________________
3 On a scale of 1 to 5, how important to your health and wellbeing was your reason for visiting today?
Not very important Very important
1 2 3 4 5
4 How good was the practitioner at each of the following?
Poor Less than Satisfactory Good Very Does not
satisfactory good apply
Being polite
Putting you at ease
Listening to you
Assessing your medical condition
Explaining your condition
and treatment
Involving you in decisions about
treatment
Providing or arranging treatment
for you

2. 5 Please decide how strongly you agree or disagree with the following statements.
Strongly Disagree Neutral Agree Strongly Does not
disagree agree apply
This practitioner will keep
information about me
confidential
This practitioner is honest
and trustworthy
6 I am confident about the practitioner’s ability to provide care Yes No
7 I would be completely happy to see the practitioner again Yes No
8 Please add any other comments that you would like to make about the practitioner.
The next questions will provide some basic information about who took part in the survey. If you are completing
this questionnaire on behalf of another, the provide details of the patient.
10 Are you: Male Female
11 Age: 18-29 30-49 50-69 70+
12 What do you consider your ethnicity to be?
_________________________________________________
This questionnaire was adapted by SM Daley (2018) from the GMC patient questionnaire available at
https://www.gmc-uk.org (2018)