* 1. When collecting your prescription did you:

* 2. How satisfied were you with the service you received?

* 3. Did you collect a prescription from this pharmacy for:

* 4. Thinking about any previous visits to the pharmacy, how would you rate the pharmacy on the following factors

  Very Poor Fairly Poor Fairly Good Very Good Don't Know
Cleanliness of pharmacy
Comfort and convenience of the waiting areas
Having in stock the medicines/appliances you need
Offering a clear and well organised layout
How long you have to wait to be served
Having somewhere available where you can speak without being overheard, if you wanted to 

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

  Very Poor Fairly Poor Fairly Good Very Good Don't Know
Being polite and taking the time to listen to what you want
Answering any questions you may have 
The service you received from the pharmacist
Providing an efficient service
The staff overall

* 6. 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
Providing advice on a current health problem or a longer term health condition
Providing general advise on leading a more healthy lifestyle
Disposing of medicines you no longer need
Providing advice on health services or information available elsewhere

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

  Yes No
Stopping Smoking
Healthy Eating
Physical Exercise

* 8. Which of the following best describes how you use this pharmacy?

* 9. Finally taking everything into account - the staff, the shop and the service provided - how would you rate this pharmacy?

* 10. If you have any comments about how the service from this pharmacy can be improved please comment below:

These last few questions are just to help us categorise your answers

* 11. How old are you?

* 12. Are you?

* 13. Which of the following apply to you?