Patient Feedback Questionnaire

Name

First NameLast Name

Patient No:

Which members of the healthcare team did you come into contact with? Tick all that apply

Which clinic did you attend today?

Outpatients

Rows	Yes definitely	Yes to some extent	Not really	Definitely not	Does Not Apply
Was the clinician/medical health practitioner polite and considerate?
Did the clinician/medical health practitioner listen to what you had to say?
Did the clinician/medical health practitioner give you enough opportunity to ask questions?
Did the clinician/medical health practitioner answer all your questions?
Did the clinician/medical health practitioner explain things in a way you could understand?
Are you involved as much as you want to be in the decisions about your care and treatment?
Did you have confidence in the clinician/medical health practitioner?
Did the clinician/medical health practitioner respect your views?
If the clinician/medical practitioner examined you, did he or she: a. Ask your permission? b. Respect your privacy and dignity?
By the end of the consultation did you feel better able to understand and/or manage your condition and your care

Inpatient Questions Section 1

Inpatient Questions Section 2

Rows	Yes definitely	Yes to some extent	Not Really	Definitely not	Does Not Apply
Were you satisfied with the treatment provided?
Were you involved as much as you wanted to be in the decisions about your care and treatment?
Did the clinician/medical health practitioner explain things in a way you could understand?
Did the clinician/medical health practitioner give you enough opportunity to ask questions?
Was the clinician/medical health practitioner polite and considerate?
Did the clinician/medical health practitioner listen to what you had to say?

Overall, how satisfied were you with the clinician/medical health practitioner that you saw?

Any additional comments?