Patient Survey - Williams Physical Therapy

How would you rate the courtesy of the staff at the reception desk?

Very Courteous	Courteous	Rude	Very Rude

How long did you wait in the reception area beyond your scheduled appointment time?

0-5 minutes	5-10 minutes	10+ minutes

How long did you wait in the exam room before the physical therapist appeared?

0-5 minutes	5-10 minutes	10+ minutes

The time the therapist spent with me during the initial evaluation

The communication between myself and the therapist in setting my goals

Explanation of therapy treatment and expected benefits

The staff's concern for my privacy

Helpful information given to myself and family about my condition

Staff’s attention to personal and specific needs

Meeting my personal goals

Staff was friendly, courteous, and professional

Overall satisfaction with my progress

Overall satisfaction with therapy services

Would you recommend this facility and its staff to your family and friends?

Please list any areas in which our service could be improved.

Would you like someone to contact you regarding your responses on this survey?

Date

Name

First Last

(optional)

Outstanding	Good	Adequate	Poor	N/A

Outstanding	Good	Adequate	Poor	N/A

Outstanding	Good	Adequate	Poor	N/A

Outstanding	Good	Adequate	Poor	N/A

Oustanding	Good	Adequate	Poor	N/A