Patient Satisfaction Survey

Your Age  Your Sex: Male or Female

How did you learn about our clinics?
(Please check all that apply).
Physician
Friend
Telephone Book
Insurance company recommendation
Former patient
Internet search
Other:

Was this your first experience with physical therapy?

Was this your first experience with this facility?

Please check the location of the problem for which you receive physical therapy
(please check all that apply).

Neck

Hip

Lower Back

Foot

Shoulder

Hand

Elbow

Knee

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

Respect for your privacy during physical therapy care.
The courtesy of your physical therapist.
The courtesy of all staff members.
Hours of operation for provision of physical therapy service.
Able to schedule initial physical therapy appointment in a timely way.
Able to easily schedule subsequent physical therapy appointments.
Length of time you waited before receiving treatment.
The location of our facility.
The parking available.
Your physical therapist's understanding of your problem or condition.
Explanation of your physical therapy treatment program.
Treatment provided by your physical therapist.
Services provided by your physical therapist aide(s).
Your instruction for discharge from physical therapy.
Overall quality of your physical therapy care.

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

I would recommend this facility to family or friends.
I would return to this facility if I required physical therapy.
Overall, I was satisfied with my experience with physical therapy.

We hope you had a good experience at Wasatch Therapy.
Your opinion and feedback are important to help us continually improve our services. Thank you!

Name (optional)    Date
Phone Number (optional)

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