Firstly, please tell us the name of your usual doctor
Any Doctor
Dr. Ahmad Zia
Dr. Julianne Whittingham-Jones
Dr. Navaid Alam
Dr. Shazia Wasim
1.
In the past 12 months, how many times have you seen a doctor from
your practice?
Choose an option...
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?
Choose an option...
Very poor
Poor
Fair
Good
Very good
Excellent
3 a)
How do you rate the hours that your practice is open for appointments?
Choose an option...
Very poor
Poor
Fair
Good
Very good
Excellent
3 b)
What additional hours would you like the practice to be open?
(please tick all that apply)
4.
Thinking of times when you want to see a particular doctor:
a)
How quickly do you usually get to see that doctor?
Choose an option...
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
b)
How do you rate this?
Choose an option...
Very poor
Poor
Fair
Good
Very good
Excellent
Does not apply
5.
Thinking of times when you are willing to see any doctor:
a)
How quickly do you usually get seen?
Choose an
option...
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
b)
How do you rate this?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
Does not apply
6.
If you need to see a GP urgently , can you normally get seen on
the same day?
Choose an
option...
Yes
No
Don't know/never needed to
7 a)
How long do you usually have to wait at the practice for your consultations
to begin?
Choose an option...
5 minutes or less
6 - 10 minutes
11 - 20 minutes
21 - 30 minutes
More than 30 minutes
7 b)
How do rate this?
Choose an option...
Very poor
Poor
Fair
Good
Very good
Excellent
8.
Thinking of times you have phoned the practice, how do you rate
the following:
a)
Ability to get through to the practice on the phone?
Choose an option...
Very poor
Poor
Fair
Good
Very good
Excellent
Don't know/ never tried
b)
Ability to speak to a doctor on the phone when you have a question
or need medical advice?
Choose an option...
Very poor
Poor
Fair
Good
Very good
Excellent
Don't know / never tried
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.
9. a)
In general, how often do you see your usual doctor ?
Choose an option...
Always
Almost always
A lot of the time
Some of the time
Almost never
Never
9. b)
How do you rate this?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
10.
Thinking about when you consult your doctor, how do you rate the
following:
a)
How thoroughly the doctor asked about your symptoms and how you
are feeling?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
Does not apply
b)
How well the doctor listens to what you had to say?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
Does not apply
c)
How well the doctor puts you at ease during your physical examination?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
Does not apply
d)
How much the doctor involves you in decisions about your care?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
Does not apply
e)
How well the doctor explains your problems or any treatment that
you need?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
Does not apply
f)
The amount of time your doctor spends with you?
Choose an option...
Very poor
Poor
Fair
Good
Very good
Excellent
Does not apply
g)
The doctor's patience with your questions or worries?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
Does not apply
h)
The doctor's caring and concern for you?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
Does not apply
11
Have you seen a nurse from your practice in the past 12 months?
Choose an option...
Yes - go to question 12
No - go to question 13
12
Thinking about the nurse(s) you have seen, how do you rate the
following:
a)
How well they listen to what you say?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
b)
The quality of care they provide?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
c)
How well they explain your health problems or any treatment that
you need?
Choose an
option...
Very poor
Poor
Fair
Good
Very good
Excellent
Finally, it will help us to understand your answers if you could tell us a little
about yourself:
13.
Are you:
Choose an
option...
Male
Female
14.
How are old are you?
Choose an option...
0-15
16-24
24-35
36-50
50-65
65 and over
15.
Do you have any 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.
Choose an option...
Yes
No
16 .
Which ethnic group do you belong to?
Choose an option...
White
Black or Black British
Asian or Asian British
Mixed
Chinese
Other Ethnic Group
17.
Is your accommodation?
Choose an option...
Owner-occupied/mortgaged
Rented or other arrangements
18.
Which of the following best describes you?
Choose an option...
Employed (full or part time, inc. self-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.