Patient Questionnaire

Q1 Why did you visit this pharmacy today?
To collect a prescription for:
Yourself Someone else Both 

If for some other reason (please write in the reason for your visit):

(If you did not collect a prescription, please go to Q3.)


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 


Q2 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 


This section is about the pharmacy and the staff who work there more generally, not just for today's visit

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:
Very poor Fairly poor Fairly good very good Don't know 
b) The comfort and convenience of the waiting areas (e.g. seating or standing room):
Very poor Fairly poor Fairly good very good Don't know 
c) Having in stock the medicines/appliances you need.
Very poor Fairly poor Fairly good very good Don't know 
d) Offering a clear and well organised layout:
Very poor Fairly poor Fairly good very good Don't know 
e) How long you have to wait to be served:
Very poor Fairly poor Fairly good very good Don't know 
f) Having somewhere available where you could speak without being overheard, if you wanted to:
Very poor Fairly poor Fairly good very good Don't know 


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 service 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:
Very poor Fairly poor Fairly good very good Don't know 
b) Answering any queries you may have:
Very poor Fairly poor Fairly good very good Don't know 
c) The service you received from the pharmacist:
Very poor Fairly poor Fairly good very good Don't know 
d) The service you received from the other pharmacy staff:
Very poor Fairly poor Fairly good very good Don't know 
e) Providing an efficient service:
Very poor Fairly poor Fairly good very good Don't know 
f) The staff overall:
Very poor Fairly poor Fairly good very good Don't know 


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 a current health problem or a longer term health condition:
Not at all well Not very well Fairly well Very well Never used 
b) Providing general advice on leading a more healthy lifestyle:
Not at all well Not very well Fairly well Very well Never used 
c) Disposing of medicines you no longer need:
Not at all well Not very well Fairly well Very well Never used 
d) Providing advice on health services or information available elsewhere:
Not at all well Not very well Fairly well Very well Never used 


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

Stopping smoking: Yes No 
Healthy eating: Yes No 
Physical exercise Yes No 


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

This is the pharmacy that you choose to visit if possible This is one of several pharmacies that you use when you need to This pharmacy was just convenient for you today 


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 


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]


These last few questions are just to help us categorise your answers

Q11 How old are you?
16-19 20-24 25-34 35-44 45-54 55-64 65+ 


Q12 Are you
Male Female 


Q 13 Which of the following apply to you:

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


Thank you for completing this questionnaire