31 Clapham High Street, London, SW4 7TR
Tel : 020 7622 3147
[email protected]
This section is about why you visited the pharmacy today
Q1   Why did you visit this pharmacy today?
To collect a prescription for:
Someone else
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
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: Very poor Fairly poor Fairly good Very good Don't know
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
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: 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
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   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?
Poor Fair Good Very good Excellent  
Q10  If you have any comments about how the service from this pharmacy could be improved, please write them in here:
Q11   How old are you?
16-19 20-24 25-34 35-44 45-54 55-64 65+  
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  
Thank you for completing this questionnaire