This section is about why you visited the pharmacy today

Q1 Why did you visit this pharmacy today?

For Yourself

Someone Else

Both

OR

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

Came back later

Waited in pharmacy

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  

Very Satisfied

Fairly 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

B)  The comfort and convenience of the
     waiting areas (e.g. seating or standing room)

C)  Having in stock the medicines/appliances you need

D)  Offering a clear and well organised layout

E)  How long you have to wait to be served

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

B)  Answering any queries you may have

C)  The service you received from the pharmacist

D)  The service you received from the other pharmacy        staff    

E)  Providing an efficient service   

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

B) Providing general advice on leading a more
    healthy lifestyle

C) Disposing of medicines you no longer need

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?

A) Stopping smoking

B) Healthy eating

C) Physical exercise

Yes         No   

Yes         No

Yes         No

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

A) This is the pharmacy that you choose to visit      if possible

B) This is one of several pharmacies that you      use when you need to

C) 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:

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:

A) You have, or care for, children under 16 ………………………….

B) You are a carer for someone with a longstanding illness or infirmity   

C) Neither …………………………………………………………………

Thank you for completing this questionnaire

COURTS PHARMACY 41, THE HEART, WALTON-ON-THAMES, SURREY, KT12 1GH

ONLY CLICK THIS BUTTON TO CLEAR THE FORM AND START AGAIN