Mountsorrel Pharmacy Questionnaire

This section is about why you visited the pharmacy today

Q1 Why did you visit this pharmacy today?

To collect a prescription for:

Yourself

Someone Else

Both

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

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

Q3a 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

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.

Are you happy with our procedures

Yes

No

If no, please comment

or do you have any concerns?

Yes

No

If Yes, please comment

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.

Has the pharmacy ever asked for your consent like this?

Yes

No

Q3d. If yes, do you feel your wishes were respected?

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:

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 What services (if any) would you like to see in this pharmacy that are not currently provided?

Other - Please state

Q8 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

Q9 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

Q10 Finally, taking everything into account - the staff, the shop and the service provided - how would you rate the pharmacy where you received this questionnaire?

Q11 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

Q12 How old are you?

Q13 Are you...

Male

Female

Q14 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

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