Please tell us the name of your usual doctor:
1. In the past 12 months, how many times have you seen a doctor from your practice?
** None None Once or twice Three or four times Five or six times Seven times or more
2. How do you rate the way you are treated by receptionists at your practice?
** None Very Poor Poor Fair Good Very Good Excellent
3a. How do you rate the hours that your practice is open for appointments?
** None Very Poor Poor Fair Good Very Good Excellent
3b. What additional hours would you like the practice to be open? (please tick all that apply)
Thinking of times when you want to see a PARTICULAR doctor?
4a. How quickly do you usually get to see that doctor?
** None Same day Next working day Within 2 working days Within 3 working days Within 4 working days 5 or more working days Does not apply
4b. How do you rate this?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
Thinking of times when you are willing to see ANY doctor:
5a. How quickly do you usually get to see that doctor?
** None Same day Next working day Within 2 working days Within 3 working days Within 4 working days 5 or more working days Does not apply
5b. How do you rate this?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
6. If you need to see a GP urgently, can you normally get seen on the same day?
** None Yes No Don't know/Never needed to
7a. How long do you usually have to wait at the practice for your consultations to begin?
** None 5 minutes or less 6 - 10 minutes 11 - 20 minutes 21 - 30 minutes More than 30 minutes
7b. How do you rate this?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
Thinking of times you have phoned the practice, how do you rate the following:
8a. Ability to get through to the practice on the phone?
** None Very Poor Poor Fair Good Very Good Excellent
8b. Ability to speak to a doctor on the phone when you have a question or need medical advice?
** None Very Poor Poor Fair Good Very Good Excellent
These next questions ask about your usual doctor . If you don´t have a 'usual doctor', answer about the one doctor at your practice who you know best. If you don´t know any of the doctors, go straight to question 11.
9a. In general, how often do you see your usual doctor?
** None Always Almost always A lot of the time Some of the time Almost never Never
9b. How do you rate this?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
Thinking about when you consult your doctor, how do you rate the following:
10a. How thoroughly the doctor asked about your symptoms and how you are feeling?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
10b. How well the doctor listens to what you had to say?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
10c. How well the doctor puts you at ease during your physical examination?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
10d. How much the doctor involves you in decisions about your care?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
10e. How well the doctor explains your problems or any treatment that you need?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
10f. The amount of time your doctor spends with you?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
10g. The doctor's patience with your questions or worries?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
10h. The doctor's caring and concern for you?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
11. Have you seen a nurse from your practice in the past 12 months?
** None Yes - go to question 12 No - go to question 13
Thinking about the nurse(s) you have seen, how do you rate the following:
12a. How well they listen to what you say?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
12b. They quality of care they provide?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
12c. How well they explain your health problems or any treatment that you need?
Rating field 0 stars 1 star 2 stars 3 stars 4 stars 5 stars
Finally, it would help us to understand your answers if you could tell us a little about yourself:
13. Are you:
** None Male Female Prefer not to say
14. How old are you?
** None 0 - 15 years 16 - 24 years 25 - 35 years 36 - 50 years 51 - 65 years Over 65 years
15. Do you have a long-standing illness, disability or infirmity? By long-standing we mean anything that has troubled you over a period of time or that is likely to affect you over a period of time.
** None Yes No
16. Which ethnic group do you belong to?
** None White Black Asian Mixed Chinese Other ethnic group
17. Is your accommodation?
** None Owner occupied/mortgaged Rented or other arrangements
18. Which of the following, best describes you?
** None Employed Unemployed and looking for work At school or in full time education Unable to work due to long-term illness Looking after your home/family Retired Other
19. We are interested in any other comments you may have. Please enter them below.
