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Name

Gender

Male

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Age

18-25

26-40

41-55

56-65

66-75

over 75

Mobile number

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Do you feel confident in the overall service offered by the practice?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

Are you able to hear your name being called over the tannoy system ( or see your name flash up on the screen) when it is your turn to be seen by the clinician?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

Is the amount of time you are typically kept waiting in the waiting room for your appointment acceptable?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

When a clinician is running very late, is the reason for such a delay explained to you?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

Are you satisfied with the typical length of time you have to wait to be given a suitable appointment to see a doctor or nurse?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

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Are you satisfied with the typical length of time it takes you to get through to reception on the telephone?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

Are you satisfied with the typical length of time you are kept waiting to speak to a receptionist if you have come in to the surgery with a query?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

Are you satisfied with the typical time it takes the practice to turn around a prescription request?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

Are you satisfied with the clarity of medical information given to you by health care professionals at the practice?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

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Do you feel in general that the clinicians at the practice treat you with respect?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

Are you satisfied that the way the doctors' dress is appropriate?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

Do you feel suitably informed about the range of services available at the practice (such as different ways of ordering your prescription, telephone consultations online appointments, pre-bookable GP appointments in the early morning/ late evening/ weekend)?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

Are you satisfied with our commitment to disability related access to healthcare?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

Are you satisfied with the mix of genders and ethnicity of the practice employees?

Please choose the closest response

Strongly yes

Yes

Generally

Sometimes

Strongly No

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What areas do you feel the practice needs to concentrate on to improve the patient experience?

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