Patient Questionnaire For Doctors - Free Download | Page 2
This questionnaire is provided and used by General Medical Council to regulate doctors and ensure good medical practice.
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Please vote for this template if it helps you.
5 Please decide how strongly you agree or disagree with the following statements by ticking one box in each line.
Strongly disagree Disagree Neutral Agree Strongly agree Does not apply
a This doctor will
about me conﬁdential
b This doctor is honest
6 I am conﬁdent about this doctor’s ability to provide care
7 I would be completely happy to see this doctor again
8 Was this visit with your usual doctor
9 Please add any other comments you want to make about this doctor.
Please note: 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.
10 Are you:
60 or over
12 What is your ethnic group Please choose one section from A to E, and then tick the appropriate box to indicate your
B Mixed C Asian or Asian British D Black or Black British E Chinese or other ethnic group
White and Black
White and Black
Any other white
White and Asian
Any other Black
Any other Mixed
Any other Asian
Please write in Please write in Please write in Please write in Please write in
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