Home
About Us
Therapists
Frederick L. Hobusch, PT, DMT, MOMT, FAAOMT
Rodney A. Miyasaki, PT, MA
Rachael A. Neumann, PT, DPT
Chiara Despain, PTA
Carolina Magleby
Services
Insurances
Request An Appointment
Contact Us
FAQs
Survey
Home
About Us
Therapists
Frederick L. Hobusch, PT, DMT, MOMT, FAAOMT
Rodney A. Miyasaki, PT, MA
Rachael A. Neumann, PT, DPT
Chiara Despain, PTA
Carolina Magleby
Services
Insurances
Request An Appointment
Contact Us
FAQs
Survey
Dear Patient:
We strive to deliver the best possible physical therapy services, we are interested in learning from patients how we might improve or enhance our services. If you recently received physical therapy services at our facility, please take a few moments to complete this questionnaire.
Please answer each descriptive question on the appropriate line. Any additional comments you wish to make are welcome; write in the "Comments" section at the end of the questionnaire. Your name on the questionnaire is optional.
Thank you very much for your feedback!
Patient Name
*
*
Indicates required field
What is your sex?
*
Male
Female
What is your age?
*
Less than 13
13-18
19-25
26-35
36-50
Over 50
Prefer not to say
How did you learn about this facility?
*
Physician
Friend
Telephone book
Insurance company recommendation
Former patient
Internet
Other
Was this your first experience with physical therapy?
*
Yes
No
Was this your first experience with this facility?
*
Yes
No
Please check the location of the problem for which you received physical therapy
*
Neck
Back
Shoulder
Elbow
Hip
Foot
Hand
Knee
Other
Please rate your degree of satisfaction with each of the following statements:
Respect for your privacy during physical therapy care:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply to Me
No Opinion
The courtesy of your physical therapist:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
The courtsey of all other staff memebers:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Hours of operation for provision of physical therapy services:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Able to schedule initial physical therapy appointment in a timely way:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Able to easily schedule subsequent physical therapy appointments:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Length of time you waited before receiving treatment:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
The location of our facility:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
The parking available:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Your physical therapist's understanding of your problem or condition:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Explanation of your physical therapy treatment program:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Treatment provided by your physical therapist:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Services provided by your physical therapist assistant(s):
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Services provided by your physical therapist's aide(s):
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Your instructions for discharge from physical therapy:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Overall quality of your physical therapy care:
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Does Not Apply To Me
No Opinion
Please rate your degree of agreement with each of the following statements:
I would recommend this facility to family or friend.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion
I would return to this facility if I required physical therapy care in the future.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion
The cost of the physical therapy services myself.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion
If I had to, I would pay for these physical therapy services myself.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion
Overall, I was satisfied with my experience with physical therapy.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion
Comments
*
Thank you for taking the time to complete this questionnaire!
Submit
