(Q1) Why did you visit this pharmacy today?

To collect a prescription for::

(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?

To collect a prescription for:

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

(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...

(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...

(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...

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

Answers:

Stopping smoking

Healthy eating

Physical exercise

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

Answers:

(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?

Answers:

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

Answers:

(Q11) How old are you?

(Q12) Are you ...?

(Q13) Which of the following apply to you ...?