Physical Therapy Patient Satisfaction Survey
Function First Physical Therapy values your feedback and input. If you could take a moment to answer the
following questions it would be greatly appreciated. We use this information to improve our services and assist
us in providing superior customer service.
Initial Contact and Availability Strongly
Disagree Disagree
Agree Strongly
Agree
• I was able to reach administrative staff during business hours.
• I was able to schedule an initial evaluation in a timely fashion.
• Insurance matters & payment were explained effectively
and clear.
• All phone calls were returned in timely fashion.
Comments: ______________________________________
____________________________________________________________________________
Your First Visit Strongly
Disagree
Somewhat
Disagree
Agree Somewhat
Agree
Strongly
Agree
• Administrative staff was professional, courteous and friendly. ▫ ▫ ▫ ▫ ▫
• I did not have to wait long for the initial evaluation to start.
▫ ▫ ▫ ▫ ▫
• The physical therapist introduced him/ herself to me personally.
• The physical therapist was professional, courteous and friendly. ▫ ▫ ▫ ▫ ▫
• The physical therapist explained my injury/problem in a way I
▫ ▫ ▫ ▫ ▫
could understand.
• The physical therapist asked what I wanted to accomplish in ▫ ▫ ▫ ▫ ▫
physical therapy.
▫ ▫ ▫ ▫ ▫
• The physical therapist clearly stated the plan of care and time frames
for physical therapy. ▫ ▫ ▫ ▫ ▫
• I have trust & confidence in my physical therapist.
▫ ▫ ▫ ▫ ▫
• The physical therapist gave me home exercises & proper
instructions at the initial evaluation. ▫ ▫ ▫ ▫ ▫
Comments: ___________________________________________
_________________________________________________________________________________
Follow Up Visits and Quality of Care Strongly
Disagree Disagree
Agree Strongly
Agree
• When I arrived for each session, my appointment began on time.
• I was consistently on time for my appointments.
• At follow-up visits, I received enough individual attention from staff.
• My home exercise program was updated frequently.
• I understood the progression of my home exercises.
• I did all that my therapist asked me to do to help myself get better
during my course of treatment.
• I had a clear understanding of my responsibilities & precautions for
my diagnosis.
• I felt treatment progressed appropriately.
• I felt my physical therapist communicated with my physician
regarding my progress.
Comments: _______________________________________
__________________________________________________________________________
Care and Outcomes
Strongly Agree Strongly
Disagree Disagree Agree
• The therapists showed me how I improved from my first visit to my
last.
• I was given clear instructions on my last visit for strategies regarding
my condition.
• I would recommend Function First Physical Therapy to friends and
family.
• I will encourage my doctor to refer more people to Function First
Physical Therapy.
Comments: _________________________________________________________________
___________________________________________________________________________
How would you rate your percentage of improvement (0-100%) from your treatment at
Function First Physical Therapy?
0-‐25%
26%-‐40%
40%-‐65%
66%-‐85%
86%-‐100%
How would you rate your overall experience at Function First Physical Therapy?
Poor Fair Average Great Fantastic
Are there any staffs members you think deserve special recognition for the work they did
with you during your care? Please Explain ______________________________________
_________________________________________________________________________
_________________________________________________________________________
What did you like least about your experience at Function First Physical Therapy?
_________________________________________________________________________
_________________________________________________________________________
What did you like most about your experience at Function First Physical Therapy?
_________________________________________________________________________
_________________________________________________________________________
How did you hear about Function First Physical Therapy?
_________________________________________________________________________
_________________________________________________________________________
What could we have done better to improve your care?
_________________________________________________________________________
_________________________________________________________________________
Name: (optional) ______________________________________________
Would you like to receive our monthly e-newsletter? E-mail: ________________________
