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Patient Satisfaction Survey-Alpharetta

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Patient Satisfaction Survey-Alpharetta Powered By Docstoc
					                                              Patient Satisfaction Survey
    Thank you for taking the time to help us become more effective at providing
    a positive experience. It is our vision that Neurosport Physical Therapy provides effective,
    quality treatments in a high-energy and enjoyable atmosphere.

    Your Age:                   <10    11-30     31-50     51-70 >71
    Your Sex:                   Male        Female
    How did you hear about Neurosport Physical Therapy? ______________
    Was this your first experience with physical therapy?        Yes    No
    Was this your first experience with Neurosport?            Yes     No
    Please indicate what body part received treatment: __________________
    Your primary therapist’s name: Chris, Other:______________
Please rate your degree of satisfaction with each of the following statements.
                                                               Time you waited before receiving treatment
Respect for your privacy during physical therapy care.         Very satisfied  Satisfied    Unsatisfied   Very poor
Very satisfied   Satisfied   Unsatisfied     Very poor
                                                               The location of Neurosport Physical Therapy
The courtesy of your physical therapist                        Very satisfied   Satisfied   Unsatisfied    Very poor
Very satisfied   Satisfied    Unsatisfied      Very poor
                                                               Your physical therapist’s understanding of your
The courtesy of all Neurosport staff members                   problem/condition
Very satisfied   Satisfied    Unsatisfied    Very poor         Very satisfied  Satisfied Unsatisfied Very poor

Hours of operation                                             Explanation of your physical therapy treatment program
Very satisfied   Satisfied    Unsatisfied      Very poor       Very satisfied   Satisfied    Unsatisfied   Very poor

Able to schedule subsequent physical therapy                   Treatment provided by your physical therapist
appointments                                                   Very satisfied  Satisfied   Unsatisfied    Very poor
Very satisfied Satisfied Unsatisfied Very poor
                                                               Overall quality of your physical therapy care
                                                               Very satisfied     Satisfied     Unsatisfied    Very poor

Please rate your response with each of the following statements.

I would recommend this facility to family or friends.
Strongly agree Agree Disagree Strongly disagree                The cost of physical therapy treatment received was
                                                               reasonable.
I would return to this facility if I required physical         Strongly agree Agree Disagree Strongly disagree
therapy.
Strongly agree Agree Disagree Strongly disagree                I enjoyed the atmosphere of Neurosport due to: (ex:
                                                               energy of staff, music, cleanliness).
Overall, I was satisfied with my experience with physical      Strongly agree     Agree      Disagree Strongly disagree
therapy.
Strongly agree Agree Disagree Strongly disagree


Additional comments: __________________________________________________________________________
_____________________________________________________________________________________________

Would you like information about Pilates, Weight Loss, Personal Training or Massage Therapy
offered at Neurosport? Please give us your email address and we’ll be glad to forward you a list of
current services available including pricing and schedules. _________________@_______________.

				
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posted:2/1/2012
language:English
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