It is our goal to give you the best possible medical care. To do so, it is important that we know your thoughts about the care you are receiving. We need to know what we are doing right and in what areas we can improve. Your comments will be strictly confidential. Thank you!

By completing this survey, you will be entered into a random drawing for a $25 MasterCard gift card!!

* 1. Visit Date:

* 2. Your Therapist's Name

* 3. Overall rating of perceived improvement: (1-10 scale with 10 being best)

* 4. Was your first appointment (evaluation) scheduled in a reasonable amount of time?

* 5. Were your therapy appointments scheduled at a convenient time of day?

* 6. The treatment I received has improved my condition/injury.

* 7. Overall the staff was professional and courteous.

* 8. I would refer a family member or friend to our office for therapy.

* 9. Please rate our practice in terms of:

  Excellent Very Good Good Fair Poor N/A
How you were treated when you arrived at the reception desk
The paperwork and cancellation policy was clearly explained
The explanation of our billing and payment policies
The amount of time the therapist spent with you
The comfort of the waiting room
The quality / space of the PT clinic
The therapist's interest in your problem
The therapist's explanation of your diagnosis
The therapist's explanation of your treatment plan and/or exercise program
The therapist's sensitivity to your pain or discomfort
The satisfaction of the treatment you received
The patient education materials/handouts provided
Notification from staff if the therapist was running behind
What is your overall rating of our Physical Therapy Department?

* 10. What did you like best about your visit?

* 11. What did you like least about your visit? How can we improve?

* 12. Additional Comments:

* 13. May we use your patient survey as a testimonial in our marketing?

* 14. Your Name and Phone Number (Optional)