EXIT

Patient Satisfaction Survey for Physical Therapy

Question Title

* 1. Which Health Center did you visit today?

Midtown Health Center

Queens Health Center

Brooklyn Health Center

Harlem Health Center

Neither - This was a video visit.

Question Title

* 2. Did the therapist provide you with exercise to do at home?

Yes

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* 3. I was able to get an appointment in 3 weeks or less of my request for a physical therapy appointment?

Yes

Question Title

* 4. Which health outcomes are most important to you (check any that apply)?

Reduced pain levels

Ability to fulfill a role, duty, job, or position

Ability to be independent and perform regular activities of daily living such as walking, showering, dressing…etc

A general feeling or sense of wellness and being healthy

Other (please list any other outcomes important to you)

Question Title

* 5. How often were you confused because therapists gave you conflicting information or advice?

Never

A Little

A Lot

Always

I saw the same therapist each visit

Never

A Little

A Lot

Always

I saw the same therapist each visit

Question Title

* 6. Overall, I am satisfied with the services I received from physical therapy.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

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* 7. Any additional comments?

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* 8. Please enter your name and phone number if you would like us to contact you in regards to your comments. (Optional)

Name

Phone Number