Patient Questionnaire

Q1 Why did you visit this pharmacy today?
To collect a prescription for:
YourselfSomeone elseBoth

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 awayWaited in pharmacyCame 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 satisfiedNot very satisfiedFairly satisfiedVery Satisfied

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 poorFairly poorFairly goodvery goodDon't know
b) The comfort and convenience of the waiting areas (e.g. seating or standing room):
Very poorFairly poorFairly goodvery goodDon't know
c) Having in stock the medicines/appliances you need.
Very poorFairly poorFairly goodvery goodDon't know
d) Offering a clear and well organised layout:
Very poorFairly poorFairly goodvery goodDon't know
e) How long you have to wait to be served:
Very poorFairly poorFairly goodvery goodDon't know
f) Having somewhere available where you could speak without being overheard, if you wanted to:
Very poorFairly poorFairly goodvery goodDon'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 poorFairly poorFairly goodvery goodDon't know
b) Answering any queries you may have:
Very poorFairly poorFairly goodvery goodDon't know
c) The service you received from the pharmacist:
Very poorFairly poorFairly goodvery goodDon't know
d) The service you received from the other pharmacy staff:
Very poorFairly poorFairly goodvery goodDon't know
e) Providing an efficient service:
Very poorFairly poorFairly goodvery goodDon't know
f) The staff overall:
Very poorFairly poorFairly goodvery goodDon'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 wellNot very wellFairly wellVery wellNever used
b) Providing general advice on leading a more healthy lifestyle:
Not at all wellNot very wellFairly wellVery wellNever used
c) Disposing of medicines you no longer need:
Not at all wellNot very wellFairly wellVery wellNever used
d) Providing advice on health services or information available elsewhere:
Not at all wellNot very wellFairly wellVery wellNever used

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

Stopping smoking: YesNo
Healthy eating: YesNo
Physical exercise YesNo

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

This is the pharmacy that you choose to visit if possibleThis is one of several pharmacies that you use when you need toThis 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?

PoorFairGoodVery goodExcellent

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]

Q11 How old are you?
16-1920-2425-3435-4445-5455-6465+

Q12 Are you
MaleFemale

Q 13 Which of the following apply to you:

You have, or care for, children under 16You are a carer for someone with a longstanding illness or infirmityNeither

Input this code:

Thank you for completing this questionnaire