In our efforts to improve the services we offer, we would appreciate it if you would take the time to complete this short questionnaire.

General Medical Council Note

Licensed doctors are expected to seek feedback and review and act upon that feedback where appropriate.  The purpose of this exercise is to provide them with information about their work through the eyes of those they treat and is intended to help inform their further development.  Please base your answers only on the consultation you have recently had with Dr Naomi Whitelaw. Answers are submitted confidentially – your name is not required.

Are you filling in this questionnaire for: *

• Yourself
• Your Child
• Your spouse or partner
• Another relative or friend

Which of the following best describes the reason you saw the doctor? (Please tick all the boxes that apply) *

• To ask for advice
• Because of an ongoing problem
• For treatment (including prescriptions)
• Because of a one-off problem
• For a routine check
• Other (please give details in the box below)

If you are filling this in for someone else, please answer the questions from the patient’s point of view.

Explanation of 'Other' (above question):

On a scale of 1 to 5 (1 = not very, 5 = very) how important to your health and wellbeing was your reason for visiting the doctor? *

• 1
• 2
• 3
• 4
• 5

How good was your doctor at being polite? *

• Poor
• Less than Satisfactory
• Satisfactory
• Good
• Very
• Does not apply

How good was your doctor at making you feel at ease? *

• Poor
• Less than Satisfactory
• Satisfactory
• Good
• Very
• Does not apply

How good was your doctor at listening to you? *

• Poor
• Less than Satisfactory
• Satisfactory
• Good
• Very
• Does not apply

How good was your doctor at assessing your medical condition? *

• Poor
• Less than Satisfactory
• Satisfactory
• Good
• Very
• Does not apply

How good was your doctor at explaining your condition and treatment? *

• Poor
• Less than Satisfactory
• Satisfactory
• Good
• Very
• Does not apply

How good was your doctor at involving you in decisions about your treatment? *

• Poor
• Less than Satisfactory
• Satisfactory
• Good
• Very
• Does not apply

How good was your doctor at providing/arranging treatment for you? *

• Poor
• Less than Satisfactory
• Satisfactory
• Good
• Very
• Does not apply

This doctor will keep information about me confidential *

• Strongly disagree
• Disagree
• Neutral
• Agree
• Strongly agree
• Does not apply

Please decide how strongly you agree or disagree with the statement by ticking one box only.

This doctor is honest and trustworthy *

• Strongly disagree
• Disagree
• Neutral
• Agree
• Strongly agree
• Does not apply

Please decide how strongly you agree or disagree with the statement by ticking one box only.

I am confident about this doctor’s ability to provide care *

• Yes
• No

I would be completely happy to see this doctor again *

• Yes
• No

Was this visit with your usual doctor? *

• Yes
• No

Please add any other comments you want to make about this doctor.

Please note: Should you choose to include specific information or your name, please know that 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 below.

Are you: *

• Female
• Male

Age: *

• Under 15
• 15 – 20
• 21 – 40
• 40 – 60
• 60 or over

What is your ethnic group? *

• White British
• White Irish
• Other White background
• White and Black Caribbean
• White and Black African
• White and Asian
• Other Mixed background
• Indian
• Pakistani
• Bangladeshi
• Other Asian background
• Caribbean
• African
• Other Black background
• Chinese
• Any other

And finally... any suggestions?

We strive to improve, so if there is anything we could have done differently or, that you think we could do to improve things, please let us know.

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