Patient Questionnaire RMS NEW

Patient Questionnaire - 14Y-3584943-P002 Thank you for taking the time to complete this questionnaire. All responses are anonymous: you will not be questioned about the answers you give and your doctor will not know how to respond to these questions. All doctors are expected to seek regular feedback from colleagues and patients about their practice. The aim of this is to provide doctors with information about their work through the eyes of their colleagues as well as the patients they treat and to highlight any areas they are performing well in or need to improve in. Below are instructions on how to complete this questionnaire. If you are unable to fill in the form, someone else may complete this on your behalf. How to fill in this form. Please do not write your name on this questionnaire. Please answer all the questions that apply to you. If you feel you cannot answer a question, please tick 'Don't know'. Please base your answers solely on the consultation you had today. If you are filling this in for someone else, please answer the questions from the patient's point of view.

Insert Date in box below:

Doctor's Name:


Are you completing this questionnaire for:


The following questions will ask you about your visit to the doctor today. If you are filling in this questionnaire on behalf of someone else, please provide the answers from their point of view. Which of the following best describes the reason you saw the doctor today? (tick all boxes that apply)


On a sale of 1 to 5, how important to your health was your reason for visiting the doctor today? 1 being not very important and 5 very important.


How good was your doctor at the following today? Being polite


Making you feel relaxed and safe


Listening to you


Assessing your medical condition


Explaining your condition & treatment


Involving you in decisions about your treatment


Providing or arranging treatment for you


Please indicate how strongly you agree or disagree with the following statements by ticking one box for each line. This doctor will keep information about me confidential.


This doctor is trustworthy and honest


Are you confident about this doctor's ability to provide care?


Are you completely happy to see this doctor again?


Was this visit / contact with your usual doctor?


Please add any other comments you wish to make about this doctor. Please note: this questionnaire is completely anonymous - do not give any information which may lead the doctor to identify you.