Patient Survey

This section is about why you visited the pharmacy today

Please Select
Why did you visit this pharmacy today?

Yourself
Someone else
Both
Other

For some other reason

Please Select
If you collected a prescription today, were you able to collect it...

Straight away
Waited in pharmacy
Came back later

Please Select
How satisfied were you with the time it took?

Not at all satisfied
Not very satisfied
Fairly satisfied
Very Satisfied

This section is about the pharmacy and the staff who work there more generally, not just for today's visit

Thinking about any previous visits as well as today's, how hould you rate the pharmacy on the following factors?

	Very poor	Fairly poor	Fairly good	Very good	Don't know
Please Select a) The cleanliness of the pharmacy
Please Select b) The comfort and convenience of the waiting areas (e.g. seating or standing room)
Please Select c) Having in stock the medicines/appliances you need
Please Select d) Offering a clear and well organised layout
Please Select e) How long you have to wait to be served
Please Select f) Having somewhere available where you could speak without being overheard, if you wanted to

Again, including any previous visits to this pharmacy, how would you rate the pharmacist and the other staff who work there?

	Very poor	Fairly poor	Fairly good	Very good	Don't know
Please Select a) Being polite and taking the time to listen to what you want
Please Select b) Answering any queries you may have
Please Select c) The service you received from the pharmacist
Please Select d) The service you received from the other pharmacy staff
Please Select e) Providing an efficient service
Please Select f) The staff overall

Thinking about all the times you have used this pharmacy, how well do you think it provides each of the following services?

	Not at all well	Not very well	Fairly well	Very well	Never used
Please Select a) Providing advice on a current health problem or a longer term health condition
Please Select b) Providing general advice on leading a more healthy lifestyle
Please Select c) Disposing of medicines you no longer need
Please Select d) Providing advice on health services or information available elsewhere

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

	Yes	No
Stopping smoking			Please Select
Healthy eating			Please Select
Physical exercise			Please Select

Please Select
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

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

Please Select

Poor	Fair	Good	Very Good	Excellent

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

Please Select
How old are you?

Please Select
Are you ...

Male
Female

Please Select

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 of infirmity
  Neither

Thank you for completing this questionnaire

Repeat Prescriptions

Free Delivery

Opening Hours

Monday - Friday

10am - 1pm & 2pm - 6pm

Saturday

10am - 12pm

Sunday

Closed

NHS Hillingdon