PATIENT SATISFACTION SURVEY
1. Who was your therapist?
MATT
 RICK
 AARON
 ANGELA
 KIM
2. What body part did we treat?
Neck
 Shoulder
 Elbow
 Wrist
 Hand
 Back
 Hip
 Knee
 Ankle
 Foot
 Other
3. What percent improvement did you experience with the treatment?
No Better
 25-50%
 51-75%
 76-100%
4. How soon were you able to make your first appointment?
Same day
 Within 2 days
 Within 1 week
 Within 2 weeks
5. The courtesy you experienced with our front office staff?
Very good
 Good
 Average
 Below Average
6. Ease of Scheduling?
Very good
 Good
 Average
 Below Average
7. The courtesy of our clinical staff?
Very good
 Good
 Average
 Below Average
8. Explanation of your problem and how your therapist planned to help you?
Very good
 Good
 Average
 Below Average
9. Respect for your confidentiality/privacy?
Very good
 Good
 Average
 Below Average
10. Cleanliness?
Very good
 Good
 Average
 Below Average
11. Explanation of benefits?
Very good
Good
 Average
 Below Average
12. Waiting time for appointment?
Very good
 Good
 Average
 Below Average
13. Explanation of home programs?
Very good
 Good
 Average
 Below Average
14. Overall Quality of Care and Services
Below Average
Average
Very good
 Good
15. What are the aspects of your care that you liked?
16. What could we have done better?
NO
17. Would you use us again?
YES
NO
18. Would you recommend us to a friend?
 YES
19. Would you like to receive our monthly e-newsletter?
YES
 NO
My email address is:
My name is :
Patient was seen in the:
Richmond Office
Ashland Office
RICHMOND
ASHLAND
P H Y S I C A L        T H E R A P Y
Orthopedic and Sports Physical Therapy