Rxsurvey

Pharmacy Patient 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 (       OR

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

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 (           Came back later (

Q3 How satisfied were you with the time it took to provide your prescription and/or any other   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       Fairly   Fairly Very     Don’t
            poor       poor     good     good     know
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... [continues]

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