Patient Satisfaction Survey
Patient Name: (optional)  
Therapist:  
Referring Doctor:  
Date :
     
     
1. Was this your first experience with physical therapy? Yes No
   
2. Why were you referred to physical therapy?
   
3. Was the front office staff helpful?
Yes No
Courteous?
 Yes No
     
4. Did you have any misunderstandings regarding your insurance benefits? Yes No
     
5. Where you able to schedule your initial evaluation within a timely manner? Yes No
     
6. Did your physical therapist clearly communicate what your expected outcomes would be? Yes No
   
7. When were you given your home exercise program?
1st visit 2nd visit last visit never
     
8. Were you able to return to the same level of activity and lifestyle? Yes No
     
9. Now that you have been discharged from therapy, how would you rate your experience at VPTS?
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
   
10. Please comment on how you believe your care could have been more effective.
     
11. Would you consider our office for further services? Yes No
   
12. Are there any successes that you would like to share with us?
     
13.OK to publish?   Yes No
 
   

 

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