Patient Survey Name First Last Email Who was your Therapist? Please rate the survey questions below based on the following scale. N/A = Not Applicable 1 = Unsatisfactory 2 = Fair 3 = Average 4 = Good 5 = ExcellentWas our staff friendly and helpful on the phone with you?* N/A 1 2 3 4 5 Have all office staff members been courteous and helpful?* N/A 1 2 3 4 5 Were your benefits adequately explained to you?* N/A 1 2 3 4 5 Have the office and treatment areas always been clean and comfortable?* N/A 1 2 3 4 5 Did the clinic have scheduled appointments at convenient times for you?* N/A 1 2 3 4 5 Was it easy to schedule your appointments?* N/A 1 2 3 4 5 Were you always seen promptly when you arrived for treatment?* N/A 1 2 3 4 5 Was the check-in process prompt and efficient?* N/A 1 2 3 4 5 Was your therapist courteous and helpful?* N/A 1 2 3 4 5 Did your physician/therapist fully explain your problem and how they would treat it?* N/A 1 2 3 4 5 Did you receive a home program and were you instructed properly in activities to do at home?* N/A 1 2 3 4 5 Would you recommend this facility to your friends or family?* N/A 1 2 3 4 5 Will you return to our practice if future care is needed?* N/A 1 2 3 4 5 How was your overall satisfaction with your experience in therapy?* N/A 1 2 3 4 5 Please share your comments:
