Form No.
Office Use
Chantry Health Group Assessment Questionnaire 2013
We would like you to complete this questionnaire about the practice and the
GP you have seen today. The doctors at the practice want to provide the
highest standard of care, feedback from this survey will enable us to identify
any areas that need improvement.
Please mark the following questions with an X.
1. In the past 12 months how many times have you seen a GP from the
practice?
1
None
2
Once or twice
3
Three of four times
4
Five or six times
5
Seven times or more
2. How do you rate the way the receptionists treat you?
1
Very Poor
2
Poor
3
Fair
4
Good
5
Very Good
6
Excellent
3. Appointment…..
A. How do you rate the hours that the
practice is open for appointments?
1
Very Poor
2
Poor
3
Fair
4
Good
5
Very Good
6
Excellent
B. What additional hours would you
like the practice to be open?
1
Early Morning
2
Lunch times
3
Evenings
4
Weekends
5
None
4. Think of times when you wanted to see a particular GP…
A. How quickly do you usually get to
see that GP?
1
Same Day
2
Next working day
3
Within 2 working days
4
Within 3 working days
5
Within 4 working days
6
5 or more working days
7
Does not apply
B. How do you rate your response to
Question 4 A. ?
1
Very Poor
2
Poor
3
Fair
4
Good
5
Very Good
6
Excellent
7
Does not apply
5. Think of times when you were willing to see any GP…
A. How quickly do you usually get
B. How do you rate your response to
seen?
Question 5 A. ?
1
Same Day
1
Very Poor
2
Next working day
2
Poor
3
Within 2 working days
3
Fair
4
Within 3 working days
4
Good
5
Within 4 working days
5
Very Good
6
5 or more working days
6
Excellent
7
Does not apply
7
Does not apply
6. If you need to see a GP urgently, can you normally get seen on the
same day?
1. Yes
2. No
3. Don’t Know
7. Waiting times …
How long do you have to wait before
your consultation begins?
1
5 minutes or less
2
6 – 10 minutes
3
11 – 20 minutes
4
21 – 30 minutes
5
More than 30 minutes
B. How do you rate this?
1
2
3
4
5
6
Very Poor
Poor
Fair
Good
Very Good
Excellent
8. Thinking of time when you have phoned through to the practice, how
do you rate…
A. Ability to get through to the practice B. Ability to speak to a GP on the
via phone?
phone when you have a medical
question or need advice?
1
Very Poor
1
Very Poor
2
Poor
2
Poor
3
Fair
3
Fair
4
Good
4
Good
5
Very Good
5
Very Good
6
Excellent
6
Excellent
7
Don’t know / Never tried
7
Don’t know / Never tried
9. This question is about your USUAL GP/the GP you know best
A. In general, how often do you see
your usual GP?
1
Always
2
Almost always
3
A lot of the time
4
Some of the time
5
Almost never
6
Never
B. How do you rate this?
1
2
3
4
5
6
Very Poor
Poor
Fair
Good
Very Good
Excellent
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10. Thinking about your consultation with your GP, how do you rate the following:
V. Poor
(1)
Poor
(2)
Fair
(3)
Good
(4)
V. Good
(5)
Excellent
(6)
N/A
(7)
a. How thoroughly the GP asked
about your symptoms and how you
are feeling
b. How well the GP listened to what
you had to say
c. How well the GP put you at ease
during physical examination
d. How much the GP involved you in
the decisions about your care
e. How well the GP explained your
problems or any treatment needed
F. The amount of time the GP spent
with you
g. The GP’s patience with your
questions and worries
h. The GP’s care and concern for
you
11. After seeing the GP today, do you feel …
Much more than A little more than
before the visit
before the visit
(1)
(2)
a. able to understand
your problem(s) or illness
b. able to cope with your
problem(s) or illness
c. able to keep yourself
healthy
The same or
less than before
the visit (3)
Does not
apply (4)
Your details
Are you:
Male (1)
Female (2)
Do you have any long-standing illness, disability or infirmary?
By long standing we mean anything that has troubled you over a period of time.
Age:
Yes
(1)
No
(2)
Which Ethnic group do you belong to?
1. White
3. Asian or Asian British
5. Chinese
2. Black or Black British
4. Mixed
6. Other
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Accommodation Status
Owner-occupied / Mortgage
Which of the following best describes you?
1. Employed (full/part of self employed)
Rented or other
5. Looking after your home/family
2. Unemployed and looking for work
6. Retired from paid work
3. At school or in full time education
7. Other (please state):
4. unable to work due to long term
sickness
We are interested in any other comments you may have such as any
praise for the practice or notes regarding any areas we could improve
on, please use the space below:
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