{"id":11810,"date":"2024-11-25T10:05:47","date_gmt":"2024-11-25T10:05:47","guid":{"rendered":"https:\/\/drducuclinics.com\/?page_id=11810"},"modified":"2024-12-10T10:39:16","modified_gmt":"2024-12-10T10:39:16","slug":"feedback","status":"publish","type":"page","link":"https:\/\/drducuclinics.com\/ar\/feedback\/","title":{"rendered":"Feedback"},"content":{"rendered":"<br><style>\r\n    \/* General *\/\r\n    .mt-5 {\r\n        margin-top: 5px;\r\n    }\r\n    .mt-10 {\r\n        margin-top: 10px;\r\n    }\r\n    .mt-15 {\r\n        margin-top: 15px;\r\n    }\r\n    .w-33 {\r\n        width: 33%;\r\n    }\r\n    .w-50 {\r\n        width: 50%;\r\n    }\r\n    .w-100 {\r\n        width: 100%;\r\n    }\r\n    .cg-50 {\r\n        column-gap: 50px;\r\n    }\r\n    .gp-custom-form {\r\n        margin-top: 10px;\r\n        margin-bottom: 50px; \r\n    }\r\n    .gp-custom-form p {\r\n        margin-bottom: 10px!important;\r\n    }\r\n    .gp-custom-form h1 {\r\n        font-size: 22px;\r\n        font-weight: bold;\r\n    }\r\n    .gp-custom-form .header-section {\r\n        display: flex;\r\n        justify-content: space-between;\r\n        align-items: flex-start;\r\n        margin-bottom: 20px;\r\n    }\r\n\r\n    .gp-custom-form .header-section .left {\r\n        max-width: 70%;\r\n    }\r\n\r\n    .gp-custom-form .header-section .right {\r\n        text-align: right;\r\n    }\r\n\r\n    .gp-custom-form .header-section .right p {\r\n        font-size: 18px;\r\n    }\r\n    .gp-custom-form .header-section .big-header {\r\n        font-size: 40px;\r\n    }\r\n\r\n    .gp-custom-form .info-box {\r\n        border: 1px solid #000;\r\n        padding: 15px;\r\n        margin-top: 10px;\r\n        font-size: 18px;\r\n    }\r\n\r\n    .gp-custom-form .info-box strong {\r\n        font-weight: bold;\r\n    }\r\n\r\n    .gp-custom-form .info-box .checkmark-example {\r\n        display: flex;\r\n        align-items: center;\r\n        margin-top: 10px;\r\n    }\r\n\r\n    .gp-custom-form .info-box .checkmark-box {\r\n        display: inline-block;\r\n        width: 16px;\r\n        height: 16px;\r\n        border: 1px solid #000;\r\n        text-align: center;\r\n        vertical-align: middle;\r\n        line-height: 16px;\r\n    }\r\n\r\n    \/* Style for the input line *\/\r\n    .gp-custom-form .header-section input {\r\n        border: none;\r\n        border-top: none!important;\r\n        border-left: none!important;\r\n        border-right: none!important;\r\n        border-bottom: 1px solid #000;\r\n        font-size: 22px;\r\n        width: 300px;\r\n        margin-left: 10px;\r\n        padding: 2px;\r\n        padding-bottom: 0!important;\r\n    }\r\n    .gp-custom-form .header-section input:focus {\r\n        outline: none;\r\n        border-bottom: 2px solid #000;\r\n    }\r\n    .gp-custom-form p {\r\n        margin-bottom: 10px!important;\r\n    }\r\n    \/* Style for the date picker *\/\r\n    .gp-custom-form .date-section {\r\n        display: flex;\r\n        align-items: center;\r\n        margin-top: 20px;\r\n    }\r\n    .gp-custom-form .date-section label {\r\n        font-size: 18px;\r\n        font-weight: bold;\r\n        margin-right: 10px;\r\n    }\r\n    .gp-custom-form .date-section input[type=\"date\"] {\r\n        font-size: 16px;\r\n        padding: 5px;\r\n        border: 1px solid #000;\r\n        border-radius: 4px;\r\n        width: max-content;\r\n    }\r\n\r\n    \/* Style for question section *\/\r\n    .gp-custom-form .question-section {\r\n        border: 1px solid #000;\r\n        padding: 15px;\r\n        margin-top: 20px;\r\n        font-size: 18px;\r\n    }\r\n    .gp-custom-form .question-section p {\r\n        font-weight: bold;\r\n        margin-bottom: 15px;\r\n    }\r\n    .gp-custom-form .question-section .checkbox-group {\r\n        display: flex;\r\n        justify-content: space-between;\r\n        align-items: center;\r\n    }\r\n    .gp-custom-form .question-section .checkbox-group label {\r\n        display: flex;\r\n        align-items: center;\r\n        font-size: 16px;\r\n    }\r\n    .gp-custom-form .question-section .checkbox-group input {\r\n        margin-right: 8px;\r\n    }\r\n    .gp-custom-form .question-section .checkbox-group input[type=\"checkbox\"],\r\n    .gp-custom-form .question-section .checkbox-group input[type=\"radio\"],\r\n    .gp-custom-form .question-section .inline-question input[type=\"radio\"],\r\n    .rating-table input[type=\"radio\"] {\r\n        appearance: none;\r\n        -webkit-appearance: none;\r\n        -moz-appearance: none;\r\n        width: 16px;\r\n        height: 16px;\r\n        border: 1px solid #000!important;\r\n        border-radius: 0px!important;\r\n        display: inline-block;\r\n        vertical-align: middle;\r\n        margin-right: 8px;\r\n        position: relative;\r\n        cursor: pointer;\r\n        padding: 10px!important;\r\n\r\n    }\r\n\r\n    .gp-custom-form .question-section .checkbox-group input[type=\"checkbox\"]:checked,\r\n    .gp-custom-form .question-section .checkbox-group input[type=\"radio\"]:checked,\r\n    .gp-custom-form .question-section .inline-question input[type=\"radio\"],\r\n    .rating-table input[type=\"radio\"]:checked {\r\n        background-color: #fff;\r\n        color: #fff;\r\n    }\r\n\r\n    .gp-custom-form .question-section .checkbox-group input[type=\"checkbox\"]:checked::after,\r\n    .gp-custom-form .question-section .checkbox-group input[type=\"radio\"]:checked::after,\r\n    .gp-custom-form .question-section .inline-question input[type=\"radio\"],\r\n    .rating-table input[type=\"radio\"]:checked::after {\r\n        content: \"\u2713\";\r\n        display: block;\r\n        text-align: center;\r\n        font-size: 20px;\r\n        color: #000;\r\n        position: absolute;\r\n        top: 2px;\r\n        left: 0;\r\n        right: 0;\r\n        bottom: 0;\r\n        line-height: 16px;\r\n    }\r\n    .gp-custom-form .question-section .checkbox-group.more-rows {\r\n        justify-content: flex-start;\r\n    }\r\n    \/* Style the rating table *\/\r\n    .rating-table {\r\n        width: 100%;\r\n        border-collapse: collapse;\r\n        margin-top: 10px;\r\n    }\r\n    .rating-table th, .rating-table td {\r\n        border: 1px solid #000;\r\n        padding: 10px;\r\n        text-align: start;\r\n    }\r\n    .rating-table th {\r\n        background-color: #f4f4f4;\r\n        font-weight: bold;\r\n    }\r\n    .rating-table td:first-child {\r\n        text-align: left;\r\n    }\r\n    .question-section-inline {\r\n        display: flex;\r\n        justify-content: flex-start;\r\n    }\r\n    .gp-custom-form p.mb-0 {\r\n        margin-bottom: 0!important;\r\n    }\r\n    .question-section textarea {\r\n        border: 1px solid #000!important;\r\n        border-radius: 0px;\r\n        padding: 5px;\r\n    }\r\n    \/* Style the race table *\/\r\n    .rating-table input[type=\"text\"] {\r\n        padding: 5px!important;\r\n        border: 1px solid #000!important;\r\n        border-radius: 0px!important;\r\n    }\r\n    \/* .tester td {\r\n        display: flex;\r\n    } *\/\r\n    @media only screen and (max-width: 767px) {\r\n        .gp-custom-form .header-section {\r\n            flex-direction: column;\r\n        }\r\n        .gp-custom-form .header-section .right {\r\n            text-align: start;\r\n        }\r\n        .gp-custom-form .question-section .checkbox-group {\r\n            flex-direction: column;\r\n            align-items: flex-start;\r\n        }\r\n        .w-33 {\r\n            width: 100%;\r\n        }\r\n        .w-50 {\r\n            width: 100%;\r\n        }\r\n        .table-container {\r\n            overflow-x: auto;\r\n            display: block;\r\n            width: 100%;\r\n        }\r\n        .question-section-inline {\r\n            flex-direction: column;\r\n        }\r\n        .gp-custom-form p.mb-0 {\r\n            margin-bottom: 10px!important;\r\n        }\r\n    }\r\n<\/style>\r\n\r\n<form class=\"gp-custom-form\" action=\"\" method=\"POST\">\r\n    <!-- Header Section -->\r\n    <div class=\"header-section\">\r\n        <div class=\"left\">\r\n            <h1>Patient questionnaire<\/h1>\r\n            <h1>for Dr <input type=\"text\" name=\"pq_name\" value=\"\"><\/h1>\r\n        <\/div>\r\n        <div class=\"right\">\r\n            <h1 class=\"big-header\">General<br> Medical<br> Council<\/h1>\r\n            <p><b>Regulating doctors<\/b><\/p>\r\n            <p><b>Ensuring good medical practice<\/b><\/p>\r\n        <\/div>\r\n    <\/div>\r\n\r\n    <!-- Info Box -->\r\n    <div class=\"info-box\">\r\n        <p>\r\n            Licensed doctors are expected to seek feedback from colleagues and patients and review and act upon that feedback where appropriate.\r\n        <\/p>\r\n        <p>\r\n            The purpose of this exercise is to provide doctors with information about their work through the eyes of those they work with and treat, and is intended to help inform their further development.\r\n        <\/p>\r\n        <p><strong>Please do not write your name on this questionnaire.<\/strong><\/p>\r\n        <p><strong>Please base your answers only on the consultation you have had today.<\/strong><\/p>\r\n        <div class=\"checkmark-example\">\r\n            <span>\r\n                Please mark the box like this <div class=\"checkmark-box\">\u2713<\/div> withs a ball point pen. If you change your mind just cross out your old response and make your new choice.\r\n            <\/span>\r\n        <\/div>\r\n    <\/div>\r\n\r\n    <!-- Date Section -->\r\n    <div class=\"date-section\">\r\n        <label for=\"date\">Please write today's date here:<\/label>\r\n        <input type=\"date\" id=\"date\" name=\"pq_date\" value=\"\">\r\n    <\/div>\r\n\r\n    <!-- Questions Section -->\r\n    <div class=\"question-section\">\r\n        <p>1. Are you filling in this questionnaire for:<\/p>\r\n        <div class=\"checkbox-group\">\r\n            <label><input type=\"radio\" name=\"pq_filling_for\" value=\"yourself\" > Yourself<\/label>\r\n            <label><input type=\"radio\" name=\"pq_filling_for\" value=\"your_child\" > Your child<\/label>\r\n            <label><input type=\"radio\" name=\"pq_filling_for\" value=\"your_spouse\" > Your spouse or partner<\/label>\r\n            <label><input type=\"radio\" name=\"pq_filling_for\" value=\"other_relative\" > Another relative or friend<\/label>\r\n        <\/div>\r\n    <\/div>\r\n    <p class=\"mt-15\"><b>If you are filling this in for someone else, please answer the following questions from the <span style=\"text-decoration: underline;\">patient's<\/span> point of view<\/b><\/p>\r\n    <div class=\"question-section\">\r\n        <p>2. Which of the following best describes the reason you saw the doctor today? (Please tick all the boxes that apply)<\/p>\r\n        <div class=\"checkbox-group more-rows\">\r\n            <label class=\"w-33\">\r\n                <input type=\"checkbox\" name=\"pq_reason[]\" value=\"advice\" \r\n                    > To ask for advice\r\n            <\/label>\r\n            <label class=\"w-33\">\r\n                <input type=\"checkbox\" name=\"pq_reason[]\" value=\"ongoing_problem\" \r\n                    > Because of an ongoing problem\r\n            <\/label>\r\n            <label class=\"w-33\">\r\n                <input type=\"checkbox\" name=\"pq_reason[]\" value=\"treatment\" \r\n                    > For treatment (including prescriptions)\r\n            <\/label>\r\n        <\/div>\r\n        <div class=\"checkbox-group more-rows\">\r\n            <label class=\"w-33\">\r\n                <input type=\"checkbox\" name=\"pq_reason[]\" value=\"one_off_problem\" \r\n                    > Because of a one-off problem\r\n            <\/label>\r\n            <label class=\"w-33\">\r\n                <input type=\"checkbox\" name=\"pq_reason[]\" value=\"routine check\" \r\n                    > For a routine check\r\n            <\/label>\r\n            <label class=\"w-33\">\r\n                <input type=\"checkbox\" name=\"pq_reason[]\" value=\"other\" \r\n                    > Other (please give details)\r\n            <\/label>\r\n        <\/div>\r\n    <\/div>\r\n\r\n    <div class=\"question-section\">\r\n        <p>3. On a scale of 1 to 5, how important to your health and wellbeing was your reason for visiting the doctor today?<\/p>\r\n        <div class=\"checkbox-group\">\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_important\" value=\"1\" \r\n                    > 1\r\n                <small style=\"margin-left: 5px;\">Not very important<\/small>\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_important\" value=\"2\" \r\n                    > 2\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_important\" value=\"3\" \r\n                    > 3\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_important\" value=\"4\" \r\n                    > 4\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_important\" value=\"5\" \r\n                    > 5\r\n                <small style=\"margin-left: 5px;\">Very important<\/small>\r\n            <\/label>\r\n        <\/div>\r\n    <\/div>\r\n\r\n    <div class=\"question-section\">\r\n        <p>4. How good was your doctor today at each of the following? (Please tick one box in each line)<\/p>\r\n        <div class=\"table-container\">\r\n            <table class=\"rating-table\">\r\n                <thead>\r\n                    <tr>\r\n                        <th><\/th>\r\n                        <th>Poor<\/th>\r\n                        <th>Less than satisfactory<\/th>\r\n                        <th>Satisfactory<\/th>\r\n                        <th>Good<\/th>\r\n                        <th>Very good<\/th>\r\n                        <th>Does not apply<\/th>\r\n                    <\/tr>\r\n                <\/thead>\r\n                <tbody>\r\n                    <tr>\r\n                        <td>a. Being polite<\/td>\r\n                        <td><input type=\"radio\" name=\"pq_polite\" value=\"poor\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_polite\" value=\"less_than_satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_polite\" value=\"satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_polite\" value=\"good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_polite\" value=\"very_good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_polite\" value=\"does_not_apply\" ><\/td>\r\n                    <\/tr>\r\n                    <tr>\r\n                        <td>b. Making you feel at ease<\/td>\r\n                        <td><input type=\"radio\" name=\"pq_at_ease\" value=\"poor\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_at_ease\" value=\"less_than_satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_at_ease\" value=\"satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_at_ease\" value=\"good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_at_ease\" value=\"very_good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_at_ease\" value=\"does_not_apply\" ><\/td>\r\n                    <\/tr>\r\n                    <tr>\r\n                        <td>c. Listening to you<\/td>\r\n                        <td><input type=\"radio\" name=\"pq_listening\" value=\"poor\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_listening\" value=\"less_than_satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_listening\" value=\"satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_listening\" value=\"good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_listening\" value=\"very_good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_listening\" value=\"does_not_apply\" ><\/td>\r\n                    <\/tr>\r\n                    <tr>\r\n                        <td>d. Assessing your medical condition<\/td>\r\n                        <td><input type=\"radio\" name=\"pq_assessing_condition\" value=\"poor\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_assessing_condition\" value=\"less_than_satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_assessing_condition\" value=\"satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_assessing_condition\" value=\"good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_assessing_condition\" value=\"very_good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_assessing_condition\" value=\"does_not_apply\" ><\/td>\r\n                    <\/tr>\r\n                    <tr>\r\n                        <td>e. Explaining your condition and treatment<\/td>\r\n                        <td><input type=\"radio\" name=\"pq_explaining\" value=\"poor\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_explaining\" value=\"less_than_satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_explaining\" value=\"satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_explaining\" value=\"good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_explaining\" value=\"very_good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_explaining\" value=\"does_not_apply\" ><\/td>\r\n                    <\/tr>\r\n                    <tr>\r\n                        <td>f. Involving you in decisions about your treatment<\/td>\r\n                        <td><input type=\"radio\" name=\"pq_involving_decisions\" value=\"poor\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_involving_decisions\" value=\"less_than_satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_involving_decisions\" value=\"satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_involving_decisions\" value=\"good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_involving_decisions\" value=\"very_good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_involving_decisions\" value=\"does_not_apply\" ><\/td>\r\n                    <\/tr>\r\n                    <tr>\r\n                        <td>g. Providing or arranging treatment for you<\/td>\r\n                        <td><input type=\"radio\" name=\"pq_providing_treatment\" value=\"poor\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_providing_treatment\" value=\"less_than_satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_providing_treatment\" value=\"satisfactory\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_providing_treatment\" value=\"good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_providing_treatment\" value=\"very_good\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_providing_treatment\" value=\"does_not_apply\" ><\/td>\r\n                    <\/tr>\r\n                <\/tbody>\r\n            <\/table>\r\n        <\/div>\r\n    <\/div>\r\n\r\n    <div class=\"question-section\">\r\n        <p>5. Please decide how strongly you agree or disagree with the following statements by ticking one box in each line<\/p>\r\n        <div class=\"table-container\">\r\n            <table class=\"rating-table\">\r\n                <thead>\r\n                    <tr>\r\n                        <th><\/th>\r\n                        <th>Strongly disagree<\/th>\r\n                        <th>Disagree<\/th>\r\n                        <th>Neutral<\/th>\r\n                        <th>Agree<\/th>\r\n                        <th>Strongly agree<\/th>\r\n                        <th>Does not apply<\/th>\r\n                    <\/tr>\r\n                <\/thead>\r\n                <tbody>\r\n                    <tr>\r\n                        <td>a. This doctor will keep informatoin about me confidential<\/td>\r\n                        <td><input type=\"radio\" name=\"pq_confidential\" value=\"strongly_disagree\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_confidential\" value=\"disagree\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_confidential\" value=\"neutral\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_confidential\" value=\"agree\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_confidential\" value=\"strongly_agree\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_confidential\" value=\"does_not_apply\" ><\/td>\r\n                    <\/tr>\r\n                    <tr>\r\n                        <td>b. This doctor is honest and trustworthy<\/td>\r\n                        <td><input type=\"radio\" name=\"pq_trustworthy\" value=\"strongly_disagree\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_trustworthy\" value=\"disagree\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_trustworthy\" value=\"neutral\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_trustworthy\" value=\"agree\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_trustworthy\" value=\"strongly_agree\" ><\/td>\r\n                        <td><input type=\"radio\" name=\"pq_trustworthy\" value=\"does_not_apply\" ><\/td>\r\n                    <\/tr>\r\n                <\/tbody>\r\n            <\/table>\r\n        <\/div>\r\n    <\/div>\r\n\r\n    <div class=\"question-section question-section-inline\">\r\n        <p class=\"w-50 mb-0\">6. I am confident about this doctor's ability to provide care<\/p>\r\n        <div class=\"checkbox-group cg-50\">\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_doctor_ability\" value=\"yes\" > Yes\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_doctor_ability\" value=\"no\" > No\r\n            <\/label>\r\n        <\/div>  \r\n    <\/div>\r\n\r\n    <div class=\"question-section question-section-inline\">\r\n        <p class=\"w-50 mb-0\">7. I would be completely happy to see this doctor again<\/p>\r\n        <div class=\"checkbox-group cg-50\">\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_see_again\" value=\"yes\" > Yes\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_see_again\" value=\"no\" > No\r\n            <\/label>\r\n        <\/div>  \r\n    <\/div>\r\n    \r\n    <div class=\"question-section question-section-inline\">\r\n        <p class=\"w-50 mb-0\">8. Was this visit with your usual doctor<\/p>\r\n        <div class=\"checkbox-group cg-50\">\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_usual_doctor\" value=\"yes\" > Yes\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_usual_doctor\" value=\"no\" > No\r\n            <\/label>\r\n        <\/div>  \r\n    <\/div>\r\n\r\n    <div class=\"question-section\">\r\n        <p>\r\n            9. Please add any other comments you want to make about this doctor.<br>\r\n            Please note: No patients will be identified when this information is given to the doctor\r\n        <\/p>\r\n        <textarea class=\"w-100\" rows=\"4\" name=\"pq_doctor_comments\"><\/textarea>\r\n    <\/div>\r\n\r\n    <p class=\"mt-15\">\r\n        <b>\r\n            The next questions will provide the doctor with some basic information about who took part in the survey. \r\n            If you are filling this in on behalf of a child or a patient with a disability, please provide details about the <span style=\"text-decoration: underline;\">patient<\/span>\r\n        <\/b>\r\n    <\/p>\r\n    \r\n    <div class=\"question-section question-section-inline\">\r\n        <p class=\"w-50 mb-0\">10. Are you:<\/p>\r\n        <div class=\"checkbox-group cg-50\">\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_gender\" value=\"female\" > Female\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_gender\" value=\"male\" > Male\r\n            <\/label>\r\n        <\/div>  \r\n    <\/div>\r\n\r\n    <div class=\"question-section\">\r\n        <div class=\"checkbox-group\">\r\n            <p class=\"mb-0\">11. Age<\/p>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_age\" value=\"under_15\" > Under 15\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_age\" value=\"15_20\" > 15-20\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_age\" value=\"21_40\" > 21-40\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_age\" value=\"40_60\" > 40-60\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"pq_age\" value=\"60_over\" > 60 or over\r\n            <\/label>\r\n        <\/div>\r\n    <\/div>\r\n\r\n    <div class=\"question-section\">\r\n        <p>\r\n            12. What is your ethnic group? Please choose one section from A to E, and then tick the appropriate box to indicate your cultural background.\r\n        <\/p>\r\n        <div class=\"table-container\">\r\n            <table class=\"rating-table\">\r\n                <thead>\r\n                    <tr>\r\n                        <th>A White<\/th>\r\n                        <th>B Mixed<\/th>\r\n                        <th>C Asian or Asian British<\/th>\r\n                        <th>D Black or Black British<\/th>\r\n                        <th>E Chinese or other ethnic group<\/th>\r\n                    <\/tr>\r\n                <\/thead>\r\n                <tbody>\r\n                    <tr>\r\n                        <td>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"british\" > British\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"irish\" > Irish\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"other_white\" data-input-id=\"pq_ethnic_group_other_white\" > Any other white background\r\n                            <\/label><br>\r\n                            <label class=\"mt-10\">\r\n                                Please write in\r\n                                <input type=\"text\" id=\"pq_ethnic_group_other_white\" class=\"w-100\" name=\"pq_ethnic_group_other_white\" value=\"\" placeholder=\"Please write in\" disabled>\r\n                            <\/label>\r\n                        <\/td>\r\n                        <td>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"white_black_caribbean\" > White and Black Caribbean\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"white_black_african\" > White and Black African\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"white_asian\" > White and Asian\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"other_mixed\" data-input-id=\"pq_ethnic_group_other_mixed\" > Any other Mixed background\r\n                            <\/label><br>\r\n                            <label class=\"mt-10\">\r\n                                Please write in\r\n                                <input type=\"text\" id=\"pq_ethnic_group_other_mixed\" class=\"w-100\" name=\"pq_ethnic_group_other_mixed\" value=\"\" placeholder=\"Please write in\" disabled>\r\n                            <\/label>\r\n                        <\/td>\r\n                        <td>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"indian\" > Indian\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"pakistani\" > Pakistani\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"bangladeshi\" > Bangladeshi\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"other_asian\" data-input-id=\"pq_ethnic_group_other_asian\" > Any other Asian background\r\n                            <\/label><br>\r\n                            <label class=\"mt-10\">\r\n                                Please write in\r\n                                <input type=\"text\" id=\"pq_ethnic_group_other_asian\" class=\"w-100\" name=\"pq_ethnic_group_other_asian\" value=\"\" placeholder=\"Please write in\" disabled>\r\n                            <\/label>\r\n                        <\/td>\r\n                        <td>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"caribbean\" > Caribbean\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"african\" > African\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"other_black\" data-input-id=\"pq_ethnic_group_other_black\" > Any other Black background\r\n                            <\/label><br>\r\n                            <label class=\"mt-10\">\r\n                                Please write in\r\n                                <input type=\"text\" id=\"pq_ethnic_group_other_black\" class=\"w-100\" name=\"pq_ethnic_group_other_black\" value=\"\" placeholder=\"Please write in\" disabled>\r\n                            <\/label>\r\n                        <\/td>\r\n                        <td>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"chinese\" > Chinese\r\n                            <\/label><br>\r\n                            <label>\r\n                                <input type=\"radio\" name=\"pq_ethnic_group\" value=\"any_other_ethnic\" data-input-id=\"pq_ethnic_group_other_ethnic\" > Any other\r\n                            <\/label><br>\r\n                            <label class=\"mt-10\">\r\n                                Please write in\r\n                                <input type=\"text\" id=\"pq_ethnic_group_other_ethnic\" class=\"w-100\" name=\"pq_ethnic_group_other_ethnic\" value=\"\" placeholder=\"Please write in\" disabled>\r\n                            <\/label>\r\n                        <\/td>\r\n                    <\/tr>\r\n                <\/tbody>\r\n            <\/table>\r\n        <\/div>\r\n    <\/div>\r\n\r\n    <p class=\"mt-15\">\r\n        The GMC is a charity registered in England and Wales (1089278) and Scotland (SCO37750)\r\n    <\/p>\r\n    <input class=\"mt-5\" type=\"submit\" value=\"submit\">\r\n<\/form>\r\n\r\n\r\n<script>\r\n    document.addEventListener('DOMContentLoaded', function () {\r\n        const radios = document.querySelectorAll('input[type=\"radio\"][data-input-id]');\r\n        const allRadios = document.querySelectorAll('input[type=\"radio\"][name=\"pq_ethnic_group\"]');\r\n        const inputs = document.querySelectorAll('input[type=\"text\"][id^=\"pq_ethnic_group_other_\"]');\r\n\r\n        let previousInput = null;\r\n\r\n        allRadios.forEach(radio => {\r\n            radio.addEventListener('change', function () {\r\n                \/\/ Disable and clear all text inputs\r\n                inputs.forEach(input => {\r\n                    input.value = '';\r\n                    input.disabled = true;\r\n                });\r\n\r\n                \/\/ If the currently selected radio has a text input associated, enable it\r\n                const inputId = this.dataset.inputId;\r\n                if (inputId) {\r\n                    const input = document.getElementById(inputId);\r\n                    if (input) {\r\n                        input.disabled = false;\r\n                        previousInput = input;\r\n                    }\r\n                } else {\r\n                    previousInput = null;\r\n                }\r\n            });\r\n        });\r\n    });\r\n<\/script>\r\n\r\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-11810","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Feedback | Dr. Ducu Clinics<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/drducuclinics.com\/ar\/feedback\/\" \/>\n<meta property=\"og:locale\" content=\"ar_AR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Feedback | Dr. Ducu Clinics\" \/>\n<meta property=\"og:url\" content=\"https:\/\/drducuclinics.com\/ar\/feedback\/\" \/>\n<meta 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