Patient Feedback Questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.PAMVR/GMC Number Date of Encounter to me the Are you filling this questionnaire in for: YourselfYour ChildYour Spouse or PartnerA Relative or FriendWhich of the following best describes the reason you saw the PA today?To ask for adviceBecause of a one-off problemBecause of an ongoing problemFor a routine check-upOn a scale of 1 to 5, how important to your health and wellbeing was your reason for visiting today? Selected Value: 1 (1 Low to 5 High)How good was your PA today at each of the following? (Please tick one box in each line) Introducing self PoorLess than SatisfactorySatisfactoryGoodVery GoodDon't KnowBeing polite PoorLess than SatisfactorySatisfactoryGoodVery GoodDon't KnowListening to youPoorLess than SatisfactorySatisfactoryGoodVery GoodDon't KnowAssessing your medical condition PoorLess than SatisfactorySatisfactoryGoodVery GoodDon't KnowExplaining your condition and treatment PoorLess than SatisfactorySatisfactoryGoodVery GoodDon't KnowInvolving you in decisions about your treatment PoorLess than SatisfactorySatisfactoryGoodVery GoodDon't KnowProviding or arranging your treatment for you PoorLess than SatisfactorySatisfactoryGoodVery GoodDon't KnowPlease decide how strongly you agree or disagree with the following statements by ticking one box in each line. This PA will keep information about me confidentialStronly DisagreeDisagreeNeutralAgreeStrongly AgreeDoes not applyThis PA is honest and trustworthy Stronly DisagreeDisagreeNeutralAgreeStrongly AgreeDoes not apply I am confident about this PAs ability to provide careStronly DisagreeDisagreeNeutralAgreeStrongly AgreeDoes not applyI would be happy to see this PA again Stronly DisagreeDisagreeNeutralAgreeStrongly AgreeDoes not applyPlease add any other comments you want to make about this PA. Please note: No patients will be identified when this information is given to the PA.Submit
