Victoria Road Surgery

50 Victoria Road, Worthing, West Sussex, BN11 1XE | Tel: 01903 230656

Durrington Health Centre, Durrington Lane, Worthing, West Sussex, BN13 2RX | Tel: 01903 230656

Current time is 03:20 - Sorry, we're closed

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Useful Forms & Leaflets

You are here:
Home
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Useful Forms & Leaflets

Useful Forms & Leaflets

Prediabetes Leaflet gives information on prediabetes

Prostate PSA Advice gives information on prostate testing and cancer

Earwax Care Leaflet gives information on clearing earwax

Asthma Annual Review Questionnaire use this form if you do not wish to attend Surgery for your annual asthma review

Practice Information Leaflet October 2019

Time to Talk Leaflet 2017 Time to Talk offer a range of talking therapies

Physiotherapy Self Referral (web) Self referral information for people over 18 years with musculoskeletal problems, such as muscle and joint pain, sports injuries, back or neck pain, sprains and strains.

PHQ-GAD7 (Web) Depression and anxiety screening

Third Party Consent Form giving permission to discuss a third party’s medical information

Change of Name or Address Form to inform us of change of details

Contraceptive Pill Request Form to request contraceptive pill

Urine Sample Test Form Form to give information on urine sample (please fill out one of the forms only)

Update your Details

Order your Prescriptions

Online Appointment Booking

Patient Participation Group

Friends and Family Test

eConsult

Useful Forms and Leaflets

COVID-19 and VACCINATION INFORMATION

Mental Health

GP Assessment Survey

Opening Times

Monday
08:00 until 18:00
Tuesday
08:00 until 18:00
Wednesday
08:00 until 18:00
Thursday
08:00 until 18:00
Friday
08:00 until 18:00
Saturday
CLOSED
Sunday
CLOSED

Useful Links

GP Assessment Survey

Dear Patient,

We would be grateful if you would complete this survey about your general practice.

Your practice wants to provide the highest standard of care. Feedback from this survey will enable the practice to identify areas that may need improvement. Your opinions are therefore very valuable.

Please answer ALL of the questions that apply to you. There are no right or wrong answers and staff will NOT be able to identify your individual responses.

Thank you.
Firstly, please tell us the name of your usual doctor*
1. In the past 12 months, how many times have you seen a doctor from your practice?*
2. How do you rate the way you are treated by receptionists at your practice?*
3a. How do you rate the hours that your practice is open for appointments?*
3b. What additional hours would you like the practice to be open?*
- Early morning
- Lunch times
- Evenings
- Weekends
- None, I am satisfied
(please tick all that apply)
4. Thinking of times when you want to see a particular doctor:
How quickly do you usually get to see that doctor?*
How do you rate this?*
5. Thinking of times when you want to see any doctor:
How quickly do you usually get seen?*
How do you rate this?*
6. If you need to see a GP urgently, can you normally get seen on the same day?*
7. How long do you usually have to wait at the practice for your consultations to begin?*
How do rate this?*
8. Thinking of times you have phoned the practice, how do you rate the following:
Ability to get through to the practice on the phone?*
Ability to speak to a doctor on the phone when you have a question or need medical advice?*
These 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.
9. In general, how often do you see your usual doctor?*
How do rate this?*
10. Thinking about when you consult your doctor, how do you rate the following:
How thoroughly the doctor asked about your symptoms and how you are feeling?*
How well the doctor listens to what you had to say?*
How well the doctor puts you at ease during your physical examination?*
How much the doctor involves you in decisions about your care?*
How well the doctor explains your problems or any treatment that you need?*
The amount of time your doctor spends with you?*
The doctor's patience with your questions or worries?*
The doctor's caring and concern for you?*
11. Have you seen a nurse from your practice in the past 12 months?*
12. Thinking about the nurse(s) you have seen, how do you rate the following:
How well they listen to what you say?*
The quality of care they provide?*
How well they explain your health problems or any treatment that you need?*
Finally, it will help us to understand your answers if you could tell us a little about yourself:
13. Are you*
14. How old are you?*
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.*
16. Which ethnic group do you belong to?*
17. Is your accommodation?*
18. Which of the following best describes you?*
19. We are interested in any other comments you may have. Please enter them below.
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