Dickman Chemist

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

Other

Note: 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

Waited in pharmacy

Come back later

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

Fairly satisfied

Very 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	Very Poor	Fairly Poor	Fairly Good	Very Good	Don't know
a) The cleanliness of the pharmacy
a) The cleanliness of the pharmacy
b) The comfort and convenience of the waiting areas (e.g. seating or standing room)
b) The comfort and convenience of the waiting areas (e.g. seating or standing room)
c) Having in stock the medicines/appliances you need
c) Having in stock the medicines/appliances you need
d) Offering a clear and well organised layout
d) Offering a clear and well organised layout
e) How long you have to wait to be served
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
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	Very Poor	Fairly Poor	Fairly Good	Very Good	Don't know
a) Being polite and taking the time to listen to what you want
a) Being polite and taking the time to listen to what you want
b) Answering any queries you may have
b) Answering any queries you may have
c) The service you received from the pharmacist
c) The service you received from the pharmacist
d) The service you received from the other pharmacy staff
d) The service you received from the other pharmacy staff
e) Providing an efficient service
e) Providing an efficient service
f) The staff overall
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	Not at all well	Not very well	Fairly well	Very well	Never used
a) Providing advice on a current health problem or a longer term health condition
a) Providing advice on a current health problem or a longer term health condition
b) Providing general advice on leading a more healthy lifestyle
b) Providing general advice on leading a more healthy lifestyle
c) Disposing of medicines you no longer need
c) Disposing of medicines you no longer need
d) Providing advice on health services or information available elsewhere
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?

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

Q8 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

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?

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

Q12 Are you?

Male	Female

Q13 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

Dickman Chemist will not pass your details on to third parties. Every effort has been made to protect you confidentiality.

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Patient Survey