Patient Questionnaire

Please complete this short questionnaire about the care you received from

Doctor ________________________________               Date ___________








Not very good


Very good


Don’t know


1 2 3 4 5 ?
1 Was your doctor polite
2 Did your doctor listen to what you wanted to say
3 Did your doctor respect your privacy and dignity when treating you
4 Did your doctor take time to assess your medical condition
5 Did your doctor explain your care / condition in a way you could understand
6 Did your doctor give you time to ask questions and answer them in a way you could understand
7 Did your doctor involve you in decisions about your treatment
8 Did the doctor respect your views and wishes
9 Did you feel confident with the advise and treatment your doctor gave you
10 Do you feel confident that your doctor is honest and trustworthy
11 Do you feel confident about this doctors ability to provide care
12 Would you be happy to be treated by this doctor again


Do you wish to make any other comment about the doctor who treated you:


Thank you