Very Poor	Poor	Fair	Good	Very Good	Excellent
2	How do you rate the way you are treated by receptionists at your practice?

		Very	Poor	Fair	Good	Very Good	Excellent
3 a)	How do you rate the hours that your practice is open for appointments?
b)	What additional hours would you like the practice to be open? (please tick all that apply)	Early Morning	Lunch times	Evenings	Weekends	None, I am satisfied

Thinking of times when you want to see a particular doctor:		Same Day	Next working day	Within 2 working days	Within 3 working days	Within 4 working days	5 or more working days	Does not apply
4 a)	How quickly do you usually get to see that doctor?
b)	How do you rate this?	Very poor	Poor	Fair	Good	Very Good	Excellent	Does not apply

Thinking of times when you want to see any doctor:		Same Day	Next working day	Within 2 working days	Within 3 working days	Within 4 working days	5 or more working days	Does not apply
5 a)	How quickly do you usually get seen?
b)	How do you rate this?	Very poor	Poor	Fair	Good	Very Good	Excellent	Does not apply

		Yes	No	Don't know/Never need to
6	If you need to see a GP urgently, can you normally get seen on the same day?

		5 minutes or less	6-10 minutes	11-20 minutes	21-30 minutes	More than 30 minutes
7 a)	How long do you usually have to wait at the practice for your consultations to begin?
b)	How do you rate this?	Very poor	Poor	Fair	Good	Very Good	Excellent

Thinking of times you have phoned the practice, how do you rate the following.		Very poor	Poor	Fair	Good	Very Good	Excellent	Dont Know/ nevertried
8 a)	Ability to get through to the practice on the phone?
b)	How do you rate this?

The next questions ask about your usual doctor. If you don’t have a ‘usual doctor’, answer about the one doctor at your practice who you know best. If you don’t know any of the doctors, go straight to question 11.

		Always	Almost always	A lot of the time	Some of the time	Almost never	Never
9 a)	In general, how often do you see your usual doctor?
b)	How do you rate this?	Very poor	Poor	Fair	Good	Very Good	Excellent

Thinking about when you consult your usual doctor, how do you rate the following.		Very poor	Poor	Fair	Good	Very good	Excellent	Does not apply
10 a)	How thoroughly the doctor asks about your symptoms and how you are feeling?
b)	How well the doctor listens to what you have to say?
c)	How well the doctor puts you at ease during your physical examination?
d)	How much the doctor involves you in decisions about your care?
e)	How well the doctor explains your problems or any treatment that you need?
f)	The amount of time your doctor spends with you?
g)	The doctors's patience with your questions?
h)	The doctor's caring and concern for you?

		Yes - go to question 12	No - go to question 13
11	Have you seen a nurse from your practice in the past 12 months?

Thinking about the nurse(s) you have seen, how do you rate the following.		Very poor	Poor	Fair	Good	Very good	Excellent	Does not apply
12 a)	How well they listen to what you say?
b)	The quality of care they provide?
c)	How well they explain your health problems or any treatment that you need?

		Male	Female
13	Are you:

14	How old are you?

		Yes	No
15	Do you have any long-standing illness, disability or infirmity? By long-standing we mean anything that has troubled you over a period of time or that is likely to affect you over a period of time.

		White	Black or Black British	Asian or Asian British	Mixed	Chinese	Other
16	Which ethnic group do you belong to?

		Owner-occupied/mortgaged	Rented or other arrangement
17	Is your accommodation:

18. Which of the following best describes you?
Employed (full or part time, including self-employed)	Unemployed and looking for work
At School or in full time education	Unable to work due to long term sickness
Other (Please Describe)

19. We are interested in any other comments you may have. Please write them here

Is there anything particlarly good about your health care?

Is there anything the could be improved?

Any other comments