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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Patient Questionnaire For Doctors Page 2
Patient Questionnaire For Doctors
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
keep information
about me confidential
b This doctor is honest
and trustworthy
6 I am confident about this doctor’s ability to provide care
Yes
No
7 I would be completely happy to see this doctor again
Yes
No
8 Was this visit with your usual doctor
Yes
No
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:
Female
Male
11 Age:
Under 15
15–20
21–40
40–60
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
cultural background.
A White
B Mixed C Asian or Asian British D Black or Black British E Chinese or other ethnic group
British
White and Black
Indian
Caribbean
Chinese
Caribbean
Irish
White and Black
Pakistani
African
Any other
African
Any other white
White and Asian
Bangladeshi
Any other Black
background background
Any other Mixed
Any other Asian
background background
Please write in Please write in Please write in Please write in Please write in
The GMC is a charity registered in England and Wales (1089278) and Scotland SCO37750)
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