Patient Care Experience (Patient 5)

Looking back, how accurate was the diagnosis you were first given?

Choose one:

• Very accurate
• Somewhat accurate
• Somewhat inaccurate
• Very inaccurate
• Not sure

How would you rate your doctor at your first consultation on each of these?

• Professional manner
• Seeing you on time
• Explaining things clearly
• Being thorough

For each row: choose one:

• Very poor
• Poor
• Fair
• Good
• Very good

Which kinds of treatment did you receive? Select all that apply.

Choose any that apply:

• Surgery
• Prescribed medication
• Physiotherapy
• Other

What other treatment did you receive?

Condition: Only when Other was selected

Open answer

Overall, how satisfied are you with the treatment you received?

Choose one:

• Very satisfied
• Somewhat satisfied
• Neither satisfied nor dissatisfied
• Somewhat dissatisfied
• Very dissatisfied

What left you dissatisfied with your treatment?

Condition: Only for dissatisfied patients

Open answer

Since your treatment ended, has any of the following happened?

• Your symptoms came back
• Your medication caused side effects
• You needed further treatment
• You found it hard to book a follow-up appointment

For each row: choose one:

• Yes
• Not sure
• No

Is there anything else about your follow-up care you would like us to know? (optional)

Open answer

Rank these stages of your care from 1 (most satisfied) to 3 (least satisfied).

• Consultation and diagnosis
• Treatment
• Follow-up after treatment

For each row: choose one from a list:

• 1
• 2
• 3

What could we do better? (optional)

Open answer

What do you think we do particularly well? (optional)

Open answer