[Clinic Logo]
[Whittall Street] clinic survey
What is this survey about?
This survey is about the care you have received in the clinic on your visit
today. It should take no longer than 10 minutes to complete. Your feedback is
important to us to help improve services at the clinic.
. Completion of this questionnaire is voluntary
If you choose not to take part in this survey it will not affect the care you
receive from the NHS in any way. If you do not wish to take part or you do not
want to answer some of the questions, you do not have to give us a reason.
Your answers will be treated in complete confidence and all responses
will be completely anonymous. Please do not write your name or address
anywhere on this questionnaire.
Completing the questionnaire

Please answer these questions about your visit to the clinic today

For each question please tick clearly inside one box.

Sometimes you will find the box you have ticked has an instruction to go
to another question. By following the instructions carefully you will miss
out questions that do not apply to you.

If you make a mistake please cross it out and put a tick in the correct
box.

Answer the questions after your clinic appointment and leave the
completed survey in the box provided in the reception area.

If you wish to take the survey home to complete please post in the pre
paid envelope.

If you have any questions about filling in the survey please contact a
member of the clinic staff or [XXXXXXX] on [XXX XXX XXXX]
©2010 University Hospitals Birmingham NHS Foundation Trust. All rights reserved
1
Please remember to answer the questions
about your visit to the clinic today.
A. BEFORE YOUR APPOINTMENT
1. How many times have you been to this
clinic before?
1
2
3
This is my first time
This is my 2nd time
More than twice
Go to Q2
Go to Q3
Go to Q3
2. Was the clinic easy to find today?
1
2
3
Yes, definitely
Yes, to some extent
No
3. Was the reception area welcoming and
friendly when you arrived at the clinic today?
1
2
3
Yes, definitely
Yes, to some extent
No
4. Were the reception staff friendly and
approachable?
1
2
3
Yes, definitely
Yes, to some extent
No
5. Was the booking-in process at reception
today organised and easy to follow?
1
2
3
Yes, definitely
Yes, to some extent
No
6. Before you attended the clinic today, did
you know what would happen during the
appointment?
1
2
3
Yes, definitely
Yes, to some extent
No
B. WAITING FOR YOUR APPOINTMENT
7. Did you make an appointment to come to
the clinic today or did you just turn up?
1

2

Made an appointment before coming
Go to Q7a
Just turned up / walk-in patient
Go to Q10
7a. Was the time and date of your pre-booked
appointment convenient for you?
1
2
3
Yes, definitely
Yes, to some extent
No
8. How long after your stated appointment
time was it until you were you seen by a
doctor or nurse?
1
2
3
4
5
Seen on time, or early Go to Q11
Waited up to 5 mins Go to Q11
Waited 6 - 15 mins Go to Q9
Waited 16 - 30 mins Go to Q9
Waited more than 30 mins
Go to Q9
6 Don’t know/Can’t remember
Go to Q9
7 I arrived late for my appointment
Go to Q9
9. Were you told how long you would have to
wait to be seen?
1
2
Yes
Go to Q11
No, but I would have liked to have
been told
Go to Q11
3 No, but I did not mind
Go to Q11
PLEASE NOW GO TO
QUESTION 11
©2010 University Hospitals Birmingham NHS Foundation Trust. All rights reserved
2
PATIENTS WITHOUT AN APPOINTMENT
D. DURING YOUR APPOINTMENT
10. When you arrived at the clinic were you
aware how long you would have to wait to be
seen by a doctor or nurse?
1
2
Yes, but the wait was shorter
Yes, and I had to wait about as long as
I was told
3 Yes, but the wait was longer
4 No, I was not told
5 Don’t know / Can’t remember
ALL PATIENTS
11. Was there enough to do while you were
waiting?
Seeing a Doctor / Consultant
13. Did you see a doctor / consultant during
today’s appointment?
1
2
2
3
Yes, definitely
Yes, to some extent
No
C. ABOUT THE CLINIC
12a. In your opinion, how clean was the
clinic?
1
2
3
4
5
Very clean
Fairly clean
Not very clean
Not at all clean
Did not notice
1
3
1
2
3
4
5
Very clean
Fairly clean
Not very clean
Not at all clean
I did not use a toilet
Yes, definitely
Yes, to some extent
No
15. Did the doctor / consultant explain the
reasons for any treatment or action in a way
that you could understand?
1
2
3
4
5
Yes, completely
Yes, to some extent
No
I did not need an explanation
No treatment or action was needed
16. Did the doctor / consultant listen to what
you had to say?
1
12b. In your opinion, how clean were the
toilets at the clinic?
Go to Q14
Go to Q19
14. Was the doctor / consultant you saw
friendly and approachable?
2
1
Yes
No
2
3
Yes, definitely
Yes, to some extent
No
17. If you had important questions to ask the
doctor / consultant, did you get answers that
you could understand?
1
2
3
4
5
Yes, definitely
Yes, to some extent
No
I did not need to ask
I did not have an opportunity to ask
©2010 University Hospitals Birmingham NHS Foundation Trust. All rights reserved
3
18. Did you have confidence and trust in the
doctor/consultant that you saw today?
1
2
3
Yes, definitely
Yes, to some extent
No
24. Did you have confidence and trust in the
nurse examining and treating you?
1
2
3
Yes, definitely
Yes, to some extent
No
Seeing a nurse
19. Did you see a nurse during today’s
appointment?
1
2
Yes
No
Go to Q20
Go to Q25
E.TESTS
25. Did you have any tests (such as swabs,
urine samples or blood tests) when you
visited the clinic today?
1
2
20. Was the nurse you saw friendly and
approachable?
1
2
3
Yes, definitely
Yes, to some extent
No
2
3
4
Yes, completely
Yes, to some extent
No
I did not need an explanation
No treatment or action was needed
5
22. Did the nurse listen to what you had to
say?
2
1
2
3
4
5
1
2
3
Yes, definitely
Yes, to some extent
No
23. If you had important questions to ask the
nurse, did you get answers that you could
understand?
1
2
3
4
5
Yes, definitely
Yes, to some extent
No
I did not need to ask
I did not have an opportunity to ask
Go to Q25a
Go to Q26
25a. Did a member of staff explain which
test(s) were being taken in a way you could
understand?
1
21. Did the nurse explain the reasons for any
treatment or action in a way that you could
understand?
Yes
No
Yes, completely
Yes, to some extent
No
It was not necessary
Don’t know / Can’t remember
25b.Did a member of staff explain what the
test(s) were for in a way you could
understand?
1
3
4
5
Yes, completely
Yes, to some extent
No
It was not necessary
Don’t know / Can’t remember
25c.Were you told clearly how you would find
out the results of your tests?
1
2
3
4
Yes, definitely
Yes, to some extent
No
 I received my results during my visit to
the clinic
5  Don’t know / Can’t remember
©2010 University Hospitals Birmingham NHS Foundation Trust. All rights reserved
4
F. OVERALL ABOUT THE APPOINTMENT
26. What was the total amount of time you
spent in the clinic today?
1
2
3
4
5
6
Less than 10 minutes
10 – 20 minutes
21 – 30 minutes
Between 30 minutes and 1 hour
60-90 minutes
Over 90 minutes
27. Was this total amount of time spent in the
clinic today acceptable to you?
1
2
3
Yes, definitely
Go to Q29
Yes, to some extent Go to Q28
No
Go to Q28
28.
If not, please state why not?
30. Were you given enough privacy when
discussing your condition or treatment?
1
2
3
31. Were you given enough privacy when
being examined or treated?

1 Yes, definitely
2 Yes, to some extent
3 No
4
2
3
a) Reception area?
2
3
Yes, definitely
Yes, to some extent
No
Yes, definitely
Yes, to some extent
No
33. Sometimes one member of staff will tell
you one thing and another will tell you
something different. Did this happen to you?
1
2
1
I was not examined or treated
32. Did doctors and/or other staff talk in front
of you as if you weren’t there?
1
29. Did you feel that your personal
information was kept confidential in each of
the following areas: (please answer sections
a, b and c):
Yes, definitely
Yes, to some extent
No
3
Yes, definitely
Go to Q34
Yes, to some extent Go to Q34
No
Go to Q35
34
If yes, please give details below
b) The waiting area?
1
2
3
Yes, definitely
Yes, to some extent
No
c) The consulting rooms/treatment areas?
1
2
3
Yes, definitely
Yes, to some extent
No
©2010 University Hospitals Birmingham NHS Foundation Trust. All rights reserved
5
G. AFTER SEEING THE DOCTOR OR
NURSE
Information
36b. Did a member of staff tell you about
medication side effects to watch for?
1
2
35. Were you offered any written or printed
information about your condition or
treatment?
1
2
Yes, and I took it Go to Q35a
Yes, but I did not take it
Go to Q36
3 No, but I would have liked it
Go to Q36
4 No, but I did not need it
Go to Q36
5 No, but I knew where to find it if I
needed it
Go to Q36
35a. Was this information clear and easy to
understand?
3
4
H. OVERALL IMPRESSION
37. Was the main reason you went to the
clinic today dealt with to your satisfaction?
1
2
3
2
3
4
Yes, definitely
Yes, to some extent
No
I have not yet read the information
2
3
2
3
36. Before you left clinic were you given any
new medications (medications that you had
not had before)?
1
2
Yes
No
Go to Q36a
Go to Q37
1
2
3
4
Yes, completely
Yes, to some extent
No
I did not need an explanation
Yes, definitely
Yes, probably
No
40. Would you recommend the clinic to a
friend?
1
2
3
36a. Did a member of staff explain to you
how to take the new medications?
Yes, all of the time
Yes, some of the time
No
39. Would you attend the clinic again if you
needed to?
1
Medications (eg. medicines, tablets,
ointments)
Yes, completely
Yes, to some extent
No
38. Overall, did you feel you were treated with
respect and dignity while you were at the
clinic?
1
1
Yes, completely
Yes, to some extent
No
I did not need this type of information
Yes, definitely
Yes, probably
No
41. Overall, how would you rate the care you
received at the clinic today?
1
2
3
4
5
6
Excellent
Very good
Good
Fair
Poor
Very poor
©2010 University Hospitals Birmingham NHS Foundation Trust. All rights reserved
6
I. ABOUT YOU
42. Are you male or female?
1 Male
2 Female
43. How old are you?
47. To which of these ethnic groups do you
belong?
a. WHITE
1 British
2
3
44. What was the main reason for attending
the clinic today? Please tick one box only
1
2
3
4
5
 Concern about symptoms
 Check-up
 Follow-up appointment
 To get test results
 Other (please specify)
Irish
Any other white background
b. MIXED
4 White and Black Caribbean
5
6
7
White and Black African
White and Asian
Any other mixed background
c. ASIAN OR ASIAN BRITISH
8 Indian
9
10
11
Pakistani
Bangladeshi
Any other Asian background
45. What language do you speak most often
at home? Please tick one box only
1
2
3
 English
 Other European language
 Asian language (such as Hindi,
Gujarati, Punjabi, Urdu, Sylheti,
Bengali, Chinese, Thai)
4
 African language (such as Swahili,
Hausa, Yoruba)
5
46. Are your sexual partners:
2
3
4
13
14
African
Any other black background
e. CHINESE OR OTHER ETHNIC GROUP
15 Chinese
16
Any other ethnic group
 Other, including British Sign
Language.
1
d. BLACK OR BLACK BRITISH
12 Caribbean
Men
Women
Both men and women
Prefer not to say
48. Did you need any help to complete this
questionnaire today (e.g. from an interpreter
or member of clinic staff?
1
2
Yes
No
©2010 University Hospitals Birmingham NHS Foundation Trust. All rights reserved
7
ANY OTHER COMMENTS
If there is anything else you would like to tell us about your experiences in the clinic, please
do so here.
Was there anything particularly good about your visit to the clinic today?
Was there anything that could have been improved?
Please list below the numbers of any questions in this survey which you found unclear and
the reasons for this.
Thank you for completing the survey
Please check you have completed all the questions
Please place the questionnaire [in the box provided in reception or post with the prepaid
envelope by XXth XXXX. No stamp is needed]
©2010 University Hospitals Birmingham NHS Foundation Trust. All rights reserved
8