Physical Therapy Survey

Location:
Age
General area of treatment (check all that apply).	Neck Back Arm Foot/Ankle Hand/Wrist Knee Other
If other please specify
Please answer the questions below by selecting the response which best describes your opinion about the treatment.	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
The office receptionist is courteous.
The registration process is handled appropriately.
The waiting area is comfortable (in terms of lighting, temperature, etc.).
My therapist spends enough time with me.
My therapist thoroughly explains the treatment(s) I receive.
My therapist treats me respectfully.
My therapist listens to my concerns.
My therapist answers all my questions.
My therapist gives me detailed instructions regarding my home program.
My therapist advises me on ways to avoid future problems.
My waiting time before treatment is no more then 15 minutes.
I would return to this office for future services or care.
I am consistently treated by the same therapist who is familiar with me.
I am able to schedule appointments for treatment at my convenience.
Please provide us with additional comments that will help us improve quality of service.(optional)
Name (optional)
Address (optional)
Phone (optional)
Email (REQUIRED)
Newsletter:	Yes, I would like to receive an email newsletter.