Patient Feedback Form

1

Birth Date

2

Gender* This field is required.

Male

Female

Prefer not to say

3

Generally, how easy or difficult is it to get through to someone at your GP Practice on the phone?* This field is required.

Very good

Good

Neither good nor poor

Poor

Very Poor

Dont know

4

How easy is it to use your GP practice’s website to look for information or access services?* This field is required.

Very good

Good

Neither good nor Poor

Poor

Very poor

Dont know

5

Were you satisfied with the appointment (or appointments) you were offered?* This field is required.

Very good

Good

Neither good nor poor

Poor

Don't know/ Cant say

Very Poor

6

Overall, how would you describe your experienceof making an appointment? * This field is required.

Very good

good

Neither good nor poor

Poor

Very poor

Dont know

8

Please can you tell us why you gave your answer?* This field is required.

9

Please tell us about anything we could have done better?* This field is required.

10

Overall, do you feel the the healthcare professional recognised or understood any mental health needs during your last appointment?* This field is required.

Yes, Definatley

Yes, to some extent

No, not at all

I did not have any mental health needs

Did not apply to my last appointment

11

Overall, how would you describe your experience of your GP practice on this occasion?* This field is required.

Very Good

Good

Neither Good Nor Poor

Fairly Poor

Very Poor

Don't know/ Cant say

13

How can we improve our service?* This field is required.