All Licensed doctors are expected to seek feedback from colleagues and patients. It is expected of Health professionals to seek feedback from colleagues and patients. They should then review and act upon that feedback where appropriate.
We are asking you to complete this form so that you can let the doctor know what you think about the care they have given you today (or your most recent consultation). The doctor involved can then take this away, and think about any improvements or adjustment they may need to make so that they can care for you, and other patients, better in the future.
We only want to know about what happened to you today (or your most recent consultation), not your general experience of this doctor.
It is important that these forms are anonymous, so please do not write your name anywhere on the sheets.
If you are completing the form on behalf of someone else please answer the questions from the patient's point of view.
Are you completing this form as
Please can you tell us your gender
Please can you tell us your age
Have you had contact with this doctor before?
How welcome and relaxed did the doctor make you feel?
How much did the doctor involve you in decisions during the consultation?
Did you feel the doctor listened to you?
Did you feel confident that the doctor's clinical knowledge was good?
Did you feel confident about the doctor's assessment?
Did you feel the doctor addressed all of your concerns?
Are you clear about what will happen next?
Do you know what to do if your condition gets worse?
How good did you feel the doctor was at caring for you?
How easy did you find it to understand what this doctor was telling you?
How confident are you that this doctor will keep information about you confidential?
How confident are you that this doctor is honest and trustworthy?
If you are happy to, please can you tell us your ethnicity?
Any other general comments