1.Are you filling in this questionnaire for:
If you are filling this in for someone else, please answer the following questions from the patient's point of view
2. Which of the following best describes the reason you saw the doctor today? ( Please tick all the boxes that apply)
3.On a scale a scale of 1-5, how important to your health & well being was your reason for visiting the doctor today?
4. How good was your doctor today at each of the following? (Please tick one box in each line)
4b Making you feel at ease
c Listening to you
4d Assessing your medical condition
4e Explaining your condition & treatment
4f Involving you in decisions about your treatment
4g Providing or arranging treatment for you
5. Please decide how strongly you agree or disagree with the following statement by ticking one box in each line.
5b The doctor is honest & trustworthy
6 I am confident about this doctor's ability to provide care
7 I would be completely happy to see this doctor again
8. Was this visit with your usual doctor
9 Please add any other comments you want to make about this doctor. Please note: No patients will be identified when this information is given to the doctor
The next questions will provide the doctor with some basic information about who took part in the survey. If you are filling this in on behalf of a child or a patient with a disability, please provide details about the patient.
10. Are you:
11. Age
12 What is your ethnic group? Please choose one section from A to E, and then tick the appropriate box to indicate your cultural background.