Problem for which you were treated

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

Please select the appropriate number and include comments for further explanation.

1. Physical therapy care was provided in a timely manner following my injury 0 1 2 3 4 5

2. It was easy to schedule all of my physical therapy appointments 0 1 2 3 4 5

3. I was seen promptly when I arrived for treatment 0 1 2 3 4 5

4. I was satisfied with the facility and its appearance 0 1 2 3 4 5

5. My physical therapist was courteous and attentive 0 1 2 3 4 5

6. The thoroughness of the examination was sufficient 0 1 2 3 4 5

7. My therapist adequately explained my diagnosis and treatment options 0 1 2 3 4 5

8. I was satisfied with the treatment provided by my physical therapist 0 1 2 3 4 5

9. The instructions my physical therapist gave me were helpful 0 1 2 3 4 5

10. The outcome of treatment prescribed was favorable 0 1 2 3 4 5

11. My home program (print & E-mail) is clearly presented and easy to follow 0 1 2 3 4 5

12. The cost of physical therapy services was reasonable 0 1 2 3 4 5

13. My expenses and insurance coverage was properly explained 0 1 2 3 4 5

14. I would recommend Sitka Physical Therapy to family or friends 0 1 2 3 4 5

15. I would return to this facility if I required physical therapy care in the future 0 1 2 3 4 5

Comments

Would you like a follow-up phone call in 2 weeks to discuss your continued progress?? yes no

If yes, at which number would you like to be reached?