Patient Feedback Questionnaire

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Patient Feedback Questionnaire

Are you filling in this questionnaire for:
Which of the following best describes the reason you saw the doctor today?
(Please tick all the boxes that apply)
On a scale of 1 to 5, how important to your health and wellbeing was your reason for visiting the doctor today?
How good was your doctor today at each of the following?
(Please hit one radio button in each line)
Please decide how strongly you agree or disagree with the following statements by selecting one radio button in each line.
(Please hit one button in each line)
I am confident about this doctor’s ability to provide care.
I would be completely happy to see this doctor again.
Was this visit with your usual doctor?
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.
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