Patient Satisfaction Questionnaire

Physical Therapy Patient Satisfaction Questionnaire

1. Your age Years

2. Your sex Male Female

3. How did you learn about this facility? (Check all that apply)

Physician	Insurance company recommendation
Friend	Former patient
Telephone Book
Other, please indicate

4. Was this your first experience with physical therapy?
Yes No

5. Was this your first experience with this facility?
Yes No

6. Please check the location of the problem for which you received physical therapy(Check all that apply)

Neck	Shoulder
Hip	Hand
Lower back	Elbow
Foot	Knee
Other, please indicate

Please rate your degree of satisfaction with each of the following statements... (1=extremely disagree,2=disagree,3=neither agree nor disagree,4=agree,5=strongly agree,6= if you have no opinion)
	1	2	3	4	5	6
7. My privacy was respected during my physical therapy care
8. My physical therapist was courteous
9. All other staff members were courteous
10. The clinic scheduled appointments at convenient times
11. I was satisfied with the treatment provided by my physical therapist
12. My first visit for physical therapy was scheduled quickly.
13. It was easy to schedule visits after my first appointment.
14. I was seen promptly when I arrived for treatment
15. The location of the facility was convenient for me
16. My bills were accurate
17. I was satisfied with the services provided by my physical therapist assistant(s)
18. Parking was available for me.
19. My physical therapist understood my problem or condition
20. The instructions my physical therapist gave me were helpful
21. I was satisfied with the overall quality of my physical therapy care
22. I would recommend this facility to family or friends
23. I would return to this facility if I required physical therapy care in the future
24. The cost of the physical therapy treatment received was reasonable
25. If I had to, I would pay for these physical therapy services myself
26. Overall, I was satisfied with my experience with physical therapy

Comments:

COAST Rehab
1820 41st Ave., Suite C
Capitola, CA 95010

831-462-1212

California Orthopedic and Sports Therapy Rehabilitation Services

Patient Satisfaction Questionnaire