Patient Feedback Questionnaire
Your opinion matters
A little bit about your visit...
Date of visit
*
-
Día
-
Mes
Año
Reason for patient visit
Where did you hear about us
Friend
Family
Doctor
Hospital
Media
Impressions of the practice
Please base all answers on this visit only. Use a score between 1 and 5, being 1 poor and 5 excellent.
How useful was the information provided to you on how to find Pixie and Sera's practice?
1
2
3
4
5
Poor
Excellent
1 is Poor, 5 is Excellent
Convenience of appointment
1
2
3
4
5
Poor
Excellent
1 is Poor, 5 is Excellent
Were our explanations about your appointment clear and easy to understand?
1
2
3
4
5
Poor
Exellent
1 is Poor, 5 is Exellent
Did you find a member of staff to talk about your worries and fears?
Yes, completely
Yes, to some extent
No
I had no worries or fears
How well did we explain the reason for any delays (if any) to you?
1
2
3
4
5
Peor
Mejor
1 is Peor, 5 is Mejor
Quality of GP Care
Doctor
Dr. Sera Shoukru
Dr. Pixie McKenna
Dr Lawen Muheden
Were you treated with privacy, respect and dignity at all times?
1
2
3
4
5
Poor
Excellent
1 is Poor, 5 is Excellent
How well did we include you in decisions about your treatment?
1
2
3
4
5
Poor
Excellent
1 is Poor, 5 is Excellent
Following your appointment did we clearly explain what happens next?
1
2
3
4
5
Poor
Excellent
1 is Poor, 5 is Excellent
Please rate the information given on who to contact if you had concerns following you appointment
1
2
3
4
5
Poor
Excellent
1 is Poor, 5 is Excellent
During the Consultation
1
2
3
4
5
Being polite
Feeling at ease
Listening
Assessing your condition
Explaining your condition and treatment
Decision about treatment
Providing treatment
If you received any medication to take home did we explain the potential side effects and what to do if you experience these?
Completely
To some extend
No
I had no medication
Would you see this doctor again?
Yes
No
Would you recommend us to your friends and family?
Yes
No
Office Administration
Poor
1
2
3
4
Excellent
5
Arrangements of referrals
Explanation of payment procedure
Method of communication
Courtesy of staff
Ease of making an appointment
Is there anything that could be improved about your experience?
Optional: Contact Details
Your Name
First Name
Last Name
E-mail
Phone Number
-
Area Code
Phone Number
Thank you!
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