Patient Satisfaction Survey

Please check the location of the problem for which you received physical therapy (check all that apply). Neck	Hip	Shoulder	Ankle	Hand	Low Back	Knee	Elbow	Foot
Other (please specify)

How did you learn about this facility? (Check all that apply) Physician	Friend	Telephone Book	Former patient	Insurance Company recommendation
Other (please specify)

Was this your first experience with Physical Therapy? Yes

No

If No, How does this experience compare? Please circle one number: 1=Disappointing, 3=Similar, 5=Superior 1

2

3

4

5

Patient Satisfaction
Exit this survey