Patient Review

Tina Khanam

Patient Feedback Questionnaire

Dear Patient

Thank you for agreeing to provide feedback on the way you have been treated by

GMC No. 6130123

Feedback from patients can help doctorsto continue to improve standards of patient care.
Your feedback is anonymous and will be collated with that from other patients to form a report for the doctor to review during their appraisal.
If you are filling in thisin forsomeone else, please answer the following questions from the patient’s point of view.

How to complete this questionnaire

• Use the rating scale (overleaf) to assess to what extent the doctor displayed the behaviour described.

• Please rate each item by circling the number that best represents your opinion as shown in this example:

1. making you feel at ease?

• If you have had no opportunity to observe this behaviour, please circle c/c (can’t comment/don’t know)

• Try to use the full range ofscores to make the strengths and weaker areasstand out

• At the end of the questionnaire you have the opportunity to add brief comments about the doctor. This will help the doctor to understand the ratings that you have given and how to improve the care provided. Edgecumbe does not endorse abusive language and any feedback containing offensive comments will be disregarded

If you have any serious concerns, about this doctor or any aspect of the care you receive, please contact the organisation directly and ask for their PAL’s liaison. They will log and handle your concern with discretion.

Practice Office
24, Fitzroy House, Lynwood Dr, Worcester Park KT4 7AT

Time: Monday-Friday 08.30-16.30 Tel:+44 7824 481120
Enquiries to:


1 Not effective/ poor
2 Partially effective/lessthan satisfactory
3 Mostly effective/ satisfactory
4 Effective/ good
5 Very effective/ very good
6 Extremely effective/ excellent
C/C Cannot Comment/Don’t Know

Using the scale above, how effective isthis doctor in:

1. making you feel at ease?
2. being polite and considerate?
3. speaking to you in a way that is easy to understand?
4. giving you enough time?
5. doing their best to find out what you might be worried about?
6. listening to you?
7. taking account of your medical history?
8. treating you with dignity?
9. involving you in deciding how to handle the problem(s) you discussed?
10. making you confident in their ability to provide safe care?
11. ensuring you getthe advice/investigation ortreatment needed?
12. checking with you that you are happy with the planned treatments or tests?
13. encouraging you to ask questions?
14. making sure you understand?
15. understanding your needs and worries?
16. explaining any risksto the treatment?
17. allowing you to make up your own mind?
18. keeping you informed about the progress of your care?
19. Overall how effectively did the doctor meet your needs as a patient?
20. Would you recommend this doctor to your friends and family?
21. Please write any other comments you’d like to make about the doctor here: