Discharge Survey- Body Gears Physical TherapyBody Gears

How are we doing?

Please take a few minutes to fill out this confidential survey. We welcome your honest feedback.

How courteous was the staff at the reception desk?

1 - Very Courteous
2 - Somewhat Courteous
3 - Neither Courteous, Nor Rude
4 - Somewhat Rude
5 - Rude

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

0 to 5 minutes
5 to 20 minutes
20 to 40 minutes
Over 40 minutes

How did you come to choose Body Gears Physical Therapy for your physical therapy needs?

Friend/relative referral
Physician referral
Online/search/review

Referral name:

How would you rate our concern for your privacy?

Outstanding
Good
Needs Improvement

Did you feel that your physical therapist spent an adequate amount of time with you?

Yes
No
N/A

Comments:

Mark all the boxes that characterize the demeanor of your physical therapist

Attentive
Concerned
Friendly
Distracted
Rushed

Other comments:

Please rate the clarity of the physical therapist's explanation of your condition and treatment options

Outstanding
Good
Adequate
Needs improvement
Poor

Other comments:

How would you rate the competence of your physical therapist?

Outstanding
Good
Adequate
Needs improvement
Poor

Other comments:

Please provide comments on your experience with our therapists and how we can improve it:

How easy was it to make an appointment?

Very Easy
Moderate
Difficult

Was the person who scheduled your appointment courteous and helpful?

1 - Very Courteous
2 - Somewhat Courteous
3 - Neither Courteous, Nor Rude
4 - Somewhat Rude
5 - Rude

Were your questions answered to your satisfaction?

Yes
No
N/A

Please provide any comments on your scheduling experience and how we can improve it.

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

Yes
No

Primary reason:

Would you like to see our clinic offer additional services?

Nutritional counseling
Personal Training
Blood pressure screening
Stress management
Yoga classes

Any other services you would be interested in?

Additional Feedback

Overall, how would you rate our services?

Please share any additional comments:

Name

First Last

Signature

Date

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

Yes
No

Can we share your comments socially? We will ensure we only use your first name!

Thank you. We rely on your feedback to help us improve our services. your input is greatly appreciated.

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How are we doing?

Additional Feedback

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