Santa Cruz Sports Medicine California Orthopedic and Sports Therapy Rehabiliation

COAST Rehab

California Orthopedic and Sports Therapy Rehabilitation Services

Santa Cruz Physical Therapy

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
6193 Soquel Drive
Aptos, CA 95003

831-462-1212