Patient Satisfaction

Name (Optional)

First Name

Last Name

Education *

Understanding your diagnosis, posture, diagnosis, body mechanics, safety awareness, precautions for condition, importance with compliance with PT recommendations.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Treatment *

Hands on treatment, modalities, exercises performed with the PT/PTA.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Satisfaction *

Satisfaction with your primary PT/PTA.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

ADL's and Work *

Ability to complete normal activities of daily living in the home or work environment since receiving treatment.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Social Activities *

Participation in sports, exercise, or recreational activities since receiving treatment.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Discharge *

Understanding PT recommendations and ability to continue your prescribed home exercise program.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent