Ask, listen, do

Ask, Listen, Do

We would like you to think about your recent experiences of our service/team.

Name of service/team:

‘I would say this is a good service/team for my friends, family, and other children to be looked after by, if they needed similar treatment to me.’
Yes
Maybe
No
Don’t know
What was good?

What could we do better?

How old are you?
1
2
3
4
5
6
7
8
9
10
Are you a girl or a boy?
Girl
Boy
Please do not use my comments:
Please do not use my comments
If a staff member filled out this form on behalf of the patient, tick here:
Staff filled out the form

Complete a survey form

CSurvey (for patients age 16+)

Are you filling in this survey for:
Yourself
Your child
Someone I care for who has accessed a service the Practice offers
Which of the following best describes the reason you contacted us today?
To ask for advice
Because of a one-off problem
Because of an ongoing problem
For a routine check
For treatment (including prescriptions and sick notes)
Other (please provide details)

On a scale of 1 to 5, how important to your health and wellbeing was your reason for contacting us today?
Not very important
Somewhat important
Important
Very important
Urgent
How good was the Practice staff who assisted you today at each of the following?
Being polite:
Poor
Satisfactory
Good
Very Good
Does Not Apply
Making you feel at ease:
Poor
Satisfactory
Good
Very Good
Does Not Apply
Listening to you:
Poor
Satisfactory
Good
Very Good
Does Not Apply
Providing explanation:
Poor
Satisfactory
Good
Very Good
Does Not Apply
(Optional) Please decide how strongly you agree or disagree with the following statements:
The Practice staff will keep information confidential:
Disagree
Agree
Does Not Apply
The Practice staff is trustworthy:
Disagree
Agree
Does Not Apply
Which of the following best describes you?
Female
Male
I prefer to self-identify (optional)
Prefer not to answer
Age:
Under 16
16-20
21-40
41-60
60 or over
In which borough do you reside?
Westminster
Royal Borough of Kensington and Chelsea, Hammersmith and Fulham
Brent, Ealing, Harrow, Hillington, Hounslow
Other London boroughs
I reside outside of London
Prefer not to answer

Make a complaint or suggestion

We appreciate your feedback!

First Name:
Last Name:
Contact Number:
Your Feedback:

Please fill out the form and a member of our team will get back to you soon.

Friends and family test form

NHS Friends and Family Test Form

We would like you to think about your recent experience of our service.

How likely are you to recommend our GP practice to friends and family if they needed similar care or treatment?
Extremely likely
Likely
Neither likely nor unlikely
Unlikely
Extremely unlikely
Don't know

Thinking about your response to this question, what is the main reason why you feel this way?

A little bit about you:

Are you male or female?
MaleFemale
What age are you?
0-1516-2425-3435-4445-5455-6465-7475-8485+
Do you consider yourself to have a disability?
YesNo
If yes, please provide details:

Which of the following best describes your ethnic background?

White
British
Irish
Other White background

Asian or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Other Asian background

Black or Black British
Caribbean
African
Other Black background

Mixed
White and Black Caribbean
White and Black African
White and Asian
Other Mixed background

Other
Anything else
I would rather not say

Are you?
The patient
The parent or carer
The patient and parent/carer

Thank you for completing the form and providing us with feedback to improve our service.

If you do not wish your anonymous comments to be shared, please tick here:
Please do not share my anonymous comments