Patient Satisfaction Questionnaire

    1. Your age (Years)

    2. Your sex
    Male   Female

    3. How did you learn about this facility?
    ( Check all that apply )
    Physician
    Insurance company recommendation
    Friend
    Former patient
    Telephone Book
    Other, please indicate

    4. Was this your first experience with physical therapy?
    Yes   No

    5. Was this your first experience with this facility?
    Yes   No

    6. Please check the location of the problem for which you received physical therapy (     Check all that apply )
    Neck      
    Shoulder 
    Hip
    Hand
    Lower back
    Elbow
    Foot
    Knee
    Other, please indicate

    Please rate your degree of satisfaction with each of the following statements...

    7. My privacy was respected during my physical therapy care
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    8. My physical therapist was courteous    
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    9. All other staff members were courteous          
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    10. The clinic scheduled appointments at convenient times   
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    11. I was satisfied with the treatment provided by my physical therapist   
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    12. My first visit for physical therapy was scheduled quickly.      
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    13. It was easy to schedule visits after my first appointment.   
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    14. I was seen promptly when I arrived for treatment      
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    15. The location of the facility was convenient for me  
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    16. My bills were accurate    
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    17. I was satisfied with the services provided by my physical therapist assistant(s) 
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    18. Parking was available for me.        
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    19. My physical therapist understood my problem or condition
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    20. The instructions my physical therapist gave me were helpful     
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    21. I was satisfied with the overall quality of my physical therapy care  
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    22. I would recommend this facility to family or friends   
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    23. I would return to this facility if I required physical therapy care in the future  
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    24. The cost of the physical therapy treatment received was reasonable 
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    25. If I had to, I would pay for these physical therapy services myself   
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

    26. Overall, I was satisfied with my experience with physical therapy     
    Extremely Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree
    No Opinion

     Comments:
    View Site in Mobile | Classic
    Share by: