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* 1. Name:

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* 2. Therapist:

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* 3. What was your overall change of symptoms from when you began treatment until now

-7 a great deal worse 0 no change 7 a great deal better
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i We adjusted the number you entered based on the slider’s scale.

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* 4. How much did you feel the therapist listened to you and your symptoms while in care?

0 Did Not Listen 10 Listened
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i We adjusted the number you entered based on the slider’s scale.

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* 5. How much did you feel the therapist assessed and diagnosed your problem?

0 Did Not assess or diagnose the problem 10 Assessed or diagnosed the problem
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i We adjusted the number you entered based on the slider’s scale.

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* 6. How well did you feel you were educated on your symptoms and learned in a way you understood?

0 Did Not educate you 10 Educate you
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i We adjusted the number you entered based on the slider’s scale.

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* 7. How involved did you feel in the rehabilitation process?

0 Was Not involved 10 Felt involved
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i We adjusted the number you entered based on the slider’s scale.

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* 8. How likely are you to return to ReShape Physical Therapy for future care?

0 Not Likely 10 Very Likely
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i We adjusted the number you entered based on the slider’s scale.

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* 9. How likely are you to recommend ReShape Physical Therapy to a family, friend, or college?

0 Not Likely 10 Very Likely
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i We adjusted the number you entered based on the slider’s scale.

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* 10. Any Comment?

0 of 10 answered
 

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