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1. Why did you visit this pharmacy today?

Yourself
Someone else
Both

2. Were you able to obtain the products, service, medicine you required today?

3. How long did you have to wait for your prescription, service or product?

Ready Immediately
Waited in Pharmacy
Came Back Later

4. How satisfied were you with the time it took to provide your prescription, service or product you required?

Very Satisfied
Fairly Satisfied
Not Very Satisfied
Not at all Satisfied

5. How satisfied were you with the following aspects of the pharmacy? *

	Very Good	Fairly Good	Fairly Poor	Very Poor	Don't know
Cleanliness	Very GoodCleanliness Very Good	Fairly GoodCleanliness Fairly Good	Fairly PoorCleanliness Fairly Poor	Very PoorCleanliness Very Poor	Don't knowCleanliness Don't know
Waiting Areas	Very GoodWaiting Areas Very Good	Fairly GoodWaiting Areas Fairly Good	Fairly PoorWaiting Areas Fairly Poor	Very PoorWaiting Areas Very Poor	Don't knowWaiting Areas Don't know
Stock of the medicines/appliances	Very GoodStock of the medicines/appliances Very Good	Fairly GoodStock of the medicines/appliances Fairly Good	Fairly PoorStock of the medicines/appliances Fairly Poor	Very PoorStock of the medicines/appliances Very Poor	Don't knowStock of the medicines/appliances Don't know
Offering a clear and well organised layout	Very GoodOffering a clear and well organised layout Very Good	Fairly GoodOffering a clear and well organised layout Fairly Good	Fairly PoorOffering a clear and well organised layout Fairly Poor	Very PoorOffering a clear and well organised layout Very Poor	Don't knowOffering a clear and well organised layout Don't know
Having somewhere available where you could speak without being overheard, if you wanted to	Very GoodHaving somewhere available where you could speak without being overheard, if you wanted to Very Good	Fairly GoodHaving somewhere available where you could speak without being overheard, if you wanted to Fairly Good	Fairly PoorHaving somewhere available where you could speak without being overheard, if you wanted to Fairly Poor	Very PoorHaving somewhere available where you could speak without being overheard, if you wanted to Very Poor	Don't knowHaving somewhere available where you could speak without being overheard, if you wanted to Don't know

6. How satisfied were you with the following aspects of the pharmacy? *

	Very Good	Fairly Good	Fairly Poor	Very Poor	Don't know
Being polite and taking the time to listen to what you want	Very GoodBeing polite and taking the time to listen to what you want Very Good	Fairly GoodBeing polite and taking the time to listen to what you want Fairly Good	Fairly PoorBeing polite and taking the time to listen to what you want Fairly Poor	Very PoorBeing polite and taking the time to listen to what you want Very Poor	Don't knowBeing polite and taking the time to listen to what you want Don't know
Answering any queries you may have	Very GoodAnswering any queries you may have Very Good	Fairly GoodAnswering any queries you may have Fairly Good	Fairly PoorAnswering any queries you may have Fairly Poor	Very PoorAnswering any queries you may have Very Poor	Don't knowAnswering any queries you may have Don't know
The service you received from the pharmacist	Very GoodThe service you received from the pharmacist Very Good	Fairly GoodThe service you received from the pharmacist Fairly Good	Fairly PoorThe service you received from the pharmacist Fairly Poor	Very PoorThe service you received from the pharmacist Very Poor	Don't knowThe service you received from the pharmacist Don't know
The service you received from the other pharmacy staff	Very GoodThe service you received from the other pharmacy staff Very Good	Fairly GoodThe service you received from the other pharmacy staff Fairly Good	Fairly PoorThe service you received from the other pharmacy staff Fairly Poor	Very PoorThe service you received from the other pharmacy staff Very Poor	Don't knowThe service you received from the other pharmacy staff Don't know
Having somewhere available where you could speak without being overheard, if you wanted to	Very GoodHaving somewhere available where you could speak without being overheard, if you wanted to Very Good	Fairly GoodHaving somewhere available where you could speak without being overheard, if you wanted to Fairly Good	Fairly PoorHaving somewhere available where you could speak without being overheard, if you wanted to Fairly Poor	Very PoorHaving somewhere available where you could speak without being overheard, if you wanted to Very Poor	Don't knowHaving somewhere available where you could speak without being overheard, if you wanted to Don't know