Broomfield Pharmacy Questionnaire

This section is about why you visited the pharmacy today

 Q1 Why did you visit this pharmacy today?

Yourself
Someone Else
Both
Straight Away
Waited in pharmacy
Came back later
Not at all satisfied
Not very satisfied
Fairly satisfied
Very satisfied

Q3b. After you receive services or advice from us, we may retain some of your health information so that we’re best placed to help when you next visit the pharmacy. We always ensure this information is safely stored and absolutely confidential.

Yes
No
Yes
No

Q3c. 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.

Yes
No
Yes
No

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:

Very Poor
Fairly Poor
Fairly Good
Very Good
Don't know
Very Poor
Fairly Poor
Fairly Good
Very Good
Don't know
Very Poor
Fairly Poor
Fairly Good
Very Good
Dont Know
Very Poor
Fairly Poor
Fairly Good
Very Good
Don't know
Very Poor
Fairly Poor
Fairly Good
Very Good
Don't know
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:

Very Poor
Fairly Poor
Fairly Good
Very Good
Don't know
Very Poor
Fairly Poor
Fairly Good
Very Good
Don't know
Very Poor
Fairly Poor
Fairly Good
Very Good
Don't know
Very Poor
Fairly Poor
Fairly Good
Very Good
Don't know
Very Poor
Fairly Poor
Fairly Good
Very Good
Don't know
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:

Not at all well
Not very well
Fairly well
Very well
Never used
Not at all well
Not very well
Fairly well
Very well
Never used
Not at all well
Not very well
Fairly well
Very well
Never used
Not at all well
Not very well
Fairly well
Very well
Never used
Blood Pressure Screening
Heart Checks
Support for Stopping Smoking
Diabetes Screening
Weight management
Sexual Health

Q8 Have you ever been given advice about any of the following by the pharmacist or pharmacy
staff?

Yes
No
Yes
No
Yes
No
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
Poor
Fair
Good
Very Good
Excellent

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

16-19
20-24
25-34
35-44
45-54
55-64
65+
Male
Female
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

Are you human ? What is 4 + 5 ?