Bayside Physical Therapy and Sports Rehabilitation, Inc.

You recently received rehabilitation services from our clinic. Your response is greatly appreciated by the entire staff and enables us to ensure the best services in our community.

Please rate each of the following questions with the following scale:
1= Excellent, 2=Good, 3= Fair, 4=Poor, 5=Unacceptable

1. YOUR PRIMARY THERAPIST	1	2	3	4	5
A. Friendly and Courteous Behavior
B. Professional Behavior
C. Professional Appearance
D. Communication Regarding Your Injury/Condition
E. Attention/Time Given to Your Needs
F. Overall Quality of Your Therapist


Please rate each of the following questions with the following scale: 1= Excellent, 2=Good, 3= Fair, 4=Poor, 5=Unacceptable
2. Office Staff	1	2	3	4	5
A. Friendly and Courteous Behavior
B. Professional Behavior
C. Professional Appearance
D. Appointment Scheduling
E. Timely Attention to Your Needs
F. Explanation of Billing/Payment Process
G. Overall Quality of Office Staff

Please rate each of the following questions with the following scale: 1= Excellent, 2=Good, 3= Fair, 4=Poor, 5=Unacceptable
3. OTHER CLINCIAL STAFF	1	2	3	4	5
A. Friendly and Courteous Behavior
B. Professional Behavior
C. Professional Appearance
D. Communication Regarding Your Treatment
E. Attention/Time Given to Your Needs
F. Overall Quality of Other Clinical Staff

Please rate each of the following questions with the following scale: 1= Excellent, 2=Good, 3= Fair, 4=Poor, 5=Unacceptable
4. CLINIC/FACILITIES	1	2	3	4	5
A. Condition/Cleanliness of Clinic
B. Parking Convenience
C. Location of Clinic
D. Overall Comfort and Appeal

Please rate each of the following questions with the following scale: 1= Excellent, 2=Good, 3= Fair, 4=Poor, 5=Unacceptable
5. OVERALL IMPRESSION	1	2	3	4	5
A. Overall Quality of This Clinic
B. Satisfaction with Your Treatment So Far

6. a.) If given the opportunity, would you recommend this clinic to others?

Yes

6. b.) If "No", why?

6. c.) Have you recommend this clinic to others?

Yes

7. Were you seen at your scheduled time?

Yes

8. Does our office offer sufficient hours?

Yes

9. Did your therapist explain to you what progress to expect after the completion of your therapy?

Yes

10 . a.) Did your therapist instruct you in exercises and/or activities to perform at home?

Yes

10. b.) Were you offered written materials?

Yes

11. Did your therapist communicate adequately with your physician?

Yes

12. a.) What do you like best about our clinic?

12. b.) What would you recommend we do to improve the quality of our clinic?

13. Which factors influenced your decision to come to this clinic? (select all that apply)

	Physician Referral			Therapist Referral
	Convenient Location			Yellow Pages/Advertising
	Insurance Referral			Employer Referral
	Friends/Family Referral			Case Manager/Rehab Nurse Referral
	Used Clinic Previously			Other (please specify):

The next few questions are for Patient Classification purposes only:

14. a.) Is this your first experience with rehabilitative therapy?

Yes

14. b.) Have you used this clinic for rehabilitation of previous injuries/condition?

Yes

15. What is your age group?

1- 25

25-35

36-45

46-55

56-65

Over 65

16. Please give the name of your primary therapist?
17. Your Full Name:
18. Telephone Number: