Reshape Pt Customer Feedback Question Title * 1. Name: OK Question Title * 2. Therapist: OK Question Title * 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 Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 4. How much did you feel the therapist listened to you and your symptoms while in care? 0 Did Not Listen 10 Listened Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 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 Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 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 Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 7. How involved did you feel in the rehabilitation process? 0 Was Not involved 10 Felt involved Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 8. How likely are you to return to ReShape Physical Therapy for future care? 0 Not Likely 10 Very Likely Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 9. How likely are you to recommend ReShape Physical Therapy to a family, friend, or college? 0 Not Likely 10 Very Likely Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 10. Any Comment? OK DONE