Patient Feedback Questionnaire
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1University Hospital Southampton
NHS
NHS Foundation Trust
Patient Feedback Questionnaire
The team at Southampton would be very grateful for your feedback on the doctor you saw today. Please give us your
honest answers and additional comments, your feedback is completely anonymous. Thank you for helping us.
How was your doctor at the following:
Making you feel at ease?
Poor
Fair
Good
Excellent
(Introducing him/herself, being warm and friendly,
treating you with respect, not being abrupt).
Listening?
Poor
Fair
Good
Excellent
(Paying close attention without rushing you. Listening,
not looking at the notes as you were talking).
Understanding your concerns?
Poor
Fair
Good
Excellent
(Making it clear to you he or she has accurately understood
your anxieties or concerns, not dismissing anything).
Explaining things clearly?
Poor
Fair
Good
Excellent
(Fully answering any questions, giving you adequate
information, not being vague).
Showing care and compassion?
Poor
Fair
Good
Excellent
(Showed genuine concern, not being indifferent or
detatched).
Making a plan with you?
Poor
Fair
Good
Excellent
(Weighing up the risks and benefits with you. Involving
you in decision making when there are choices).
Would you be happy to see
How old are
Yes
No
25 or under
26-65
Over 65
this doctor again?
you?
Please could you indicate your ethnic group
Is English your first
language?
White British
White Irish
White Other
Chinese
Caribbean
Yes
No
Indian
Pakistani
Bangladeshi
African
Mixed race
Please turn over
Please write any
comments about the
visit on the reverse of
Other ethnic group - please let us know
this sheet.
Date:
Doctor identifier:
Outpatient clinic / clincal area:
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Parent category: Life