Home
Information for Patients
Information for GPs

Patient Feedback Form

Your feedback is handled confidentially at all times and not shared with anyone else without your explicit permission.

Patient Feedback Form

Your Name(Required)

What was the problem or problems that you had acupuncture treatment for?(Required)

Thinking back to when you started treatment, how bad was the problem on a scale from 1 (not so bad) to 10 (unbearable)?(Required)

Please enter a number from 1 to 10.

Thinking back, how often would you have this problem? From 1 (rarely) to 10 (ALL the time)?(Required)

Please enter a number from 1 to 10.

Did you take medication to manage the problem?(Required)

Yes, I took medication

No, I did not take medication

What medication did you take?

How often did you take the medication?

How much did you take?

Think about how the same problem is now. On a scale from 1 to 10, how bad is it now?(Required)

Please enter a number from 1 to 10.

At the moment, how often do you have this problem? From 1 (rarely) to 10 (ALL the time)?(Required)

Please enter a number from 1 to 10.

At the moment, do you take medication to manage the problem?(Required)

Yes, I am taking medication

No, I am not taking medication

What medication are you taking?

How often do you take it?

How much do you take?

Did you experience any change in your symptoms since receiving treatment?(Required)

Yes, much improvement

Yes, a little improvement

Neither improved nor worsened

Yes, a little worse

Yes, much worse

Please describe the change you experienced.

Do you feel this change in your symptoms was due to the acupuncture treatment you received?(Required)

Yes, definitely

Yes, possibly

No, I don’t feel it’s related

Did you benefit from treatment in other ways? If so, how?

Is there anything else you would like to mention?

Do you consent to your feedback being shared anonymously within the participating practices who provide the Acupuncture clinic?

Yes, I consent.

No, I don’t consent.

Do you consent to your feedback being shared with your GP?

Yes, I consent.

No, I don’t consent.

Can we contact you for further information about your acupuncture treatment?

Yes

No

Do you prefer to be contacted by Email or Phone?

Email

Phone

What is your email address or phone number

Name

This field is for validation purposes and should be left unchanged.

Δ

Thank you for providing your feedback. It helps us better understand and develop this service. Your participation is much appreciated.

Belgravia Surgery

26 Eccleston StreetLondonSW1W 9PY

Tuesdays 10:30AM - 5:30PM

Kings College NHS Health Centre

Bush House, 3rd Floor, South East Wing, 300 StrandLondonWC2R 4AE

Wednesdays 9:30AM - 2:00PM

Cancellations and Rebookings

Contact Kings College NHS Health Centrekingscollegehc@nhs.net0204 548 9842