Q1) Why did you visit this pharmacy today?

To collect a prescription for:		Or for some other reason... please give reason(s) below:
Yourself Someone else Both
* If you did not collect a prescription, please give reason for your visit in the section above and then go to Q3

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             Q2) If you collected a prescription today, were you able to collect it straight away, did you have to wait in the pharmacy or did you come back later to collect it?

Straight away

Waited in pharmacy

Came back later

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            Q3) How satisfied were you with the time it took to provide your prescription and/or any other NHS services you required?

Not at all satisfied

Not very satisfied

Fairly satisfied

Very satisfied

            a) After you receive services or advice from us, we may retain some of your health information so that we are best placed to help when you next visit the pharmacy. We always ensure this information is safely stored and kept absolutely confidential.
 

Are you unhappy with our procedures or do you have any concerns?

Yes No

            b) In certain circumstances, the pharmacy may need to ask your consent to share your data with another healthcare professional to support your care. We will never pass on your health information without your express permission.

Has the pharmacy ever asked for your consent like this?

Yes No

If yes, do you feel your wishes were respected?

Yes No

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            Q4) Thinking about any previous visits as well as today's, how would you rate the pharmacy on the following factors?

* Please tick one box for each aspect of the pharmacy listed below to show how good or poor you think it is:
                                                   

ANSWERS
a) The Cleanliness of the pharmacy	0 1 2 3 4
b) The Comfort and convenience of the waiting areas (e.g. seating or standing room)	0 1 2 3 4
c) Having in stock the medicines/appliances you need	0 1 2 3 4
d) Offering a clear and well organised layout	0 1 2 3 4
e) How long you have to wait to be served	0 1 2 3 4
f) Having somewhere available where you could speak without being overheard, if you wanted to	0 1 2 3 4

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            Q5) Again, including any previous visits to this pharmacy, how would you rate the pharmacist and the other staff who work there?

* Please tick one box for each aspect of the pharmacy listed below to show how good or poor you think it is:                             

ANSWERS
a) Being polite and taking the time to listen to what you want	0 1 2 3 4
b) Answering any queries you may have	0 1 2 3 4
c) The service you received from the pharmacist	0 1 2 3 4
d) The service you received from the other pharmacy staff	0 1 2 3 4
e) Providing an efficient service	0 1 2 3 4
f) The staff overall	0 1 2 3 4

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            Q6) Thinking about all the times you have used this pharmacy, how well do you think it provides each of the following services?                                      

ANSWERS
a) Providing advice on current health problem or a longer term health condition	0 1 2 3 4
b) Providing general advice on leading a more healthy lifestyle	0 1 2 3 4
c) Disposing of medicines you no longer need	0 1 2 3 4
d) Providing advice on health services or information available elsewhere	0 1 2 3 4

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            Q7) Have you ever been given advice about any of the following by the pharmacist or the pharmacy staff?

a) Stopping smoking	Yes No
b) Healthy eating	Yes No
c) Physical exercise	Yes No

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            Q8) Which of the following best describes how you use this pharmacy?

a) This is the pharmacy that you choose to visit if possible	Yes No
b) This is one of several pharmacies that you use when you need to	Yes No
c) This pharmacy was just convenient for you today	Yes No

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            Q9) Finally, taking everything into account - the staff, the shop and the service provided - how would you rate the pharmacy where you received this questionnaire?

Poor

Fair

Good

Very Good

Excellent

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            Q10) If you have any comments about how the service from this pharmacy could be improved, please write them in here:

* Insert here, if required, additional questions relating to healthcare service provision

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            Q11) How old are you?

16-19

20-24

25-34

35-44

45-54

55-64

65+

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            Q12) Are you?

Male

Female

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            Q13) Which of the following applies to you?

You have, or care for, children under 16.
You are a carer for someone with a longstanding illness or infirmity.
Neither

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