Rehabilitation Services Patient Survey

1
Which facility did you visit?
Doctors Hospital Collins Ave Rehab Center
Doctors Hospital Cable Beach Rehab Center
Doctors Hospital Homecare
Doctors Hospital Harborside
Doctors Hospital West (Blake Road)
2
Was this your first series of visits?
Yes
No
3
Which unit did you visit?
Occupational Therapy
Physical Therapy
Speech Language Pathology
4
What is your overall impression of the Rehab Department?
Fair
Average
Good
Very Good
Excellent
5
What is your impression of the Therapists?
Fair
Average
Good
Very Good
Excellent
Skill
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Efficiency
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Professionalism
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Helpfulness
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Courtesy/Friendliness
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Explanation of Exercises
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Concern for Privacy
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Included you in the Decision in regards to your treatment
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Skill
Efficiency
Professionalism
Helpfulness
Courtesy/Friendliness
Explanation of Exercises
Concern for Privacy
Included you in the Decision in regards to your treatment
Fair
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Average
Row 0, Column 1
Good
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Very Good
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Excellent
Row 0, Column 4
Fair
Row 1, Column 0
Average
Row 1, Column 1
Good
Row 1, Column 2
Very Good
Row 1, Column 3
Excellent
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Fair
Row 2, Column 0
Average
Row 2, Column 1
Good
Row 2, Column 2
Very Good
Row 2, Column 3
Excellent
Row 2, Column 4
Fair
Row 3, Column 0
Average
Row 3, Column 1
Good
Row 3, Column 2
Very Good
Row 3, Column 3
Excellent
Row 3, Column 4
Fair
Row 4, Column 0
Average
Row 4, Column 1
Good
Row 4, Column 2
Very Good
Row 4, Column 3
Excellent
Row 4, Column 4
Fair
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Average
Row 5, Column 1
Good
Row 5, Column 2
Very Good
Row 5, Column 3
Excellent
Row 5, Column 4
Fair
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Average
Row 6, Column 1
Good
Row 6, Column 2
Very Good
Row 6, Column 3
Excellent
Row 6, Column 4
Fair
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Average
Row 7, Column 1
Good
Row 7, Column 2
Very Good
Row 7, Column 3
Excellent
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6
Did you receive discharge instructions?
Yes
No
Not applicable (Please select this option if form is being completed prior to discharge)
7
What was your impression of the Department's environment/ accommodations?
Fair
Average
Good
Very Good
Excellent
Comfort
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Cleanliness
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Temperature
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Noise Level
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Decor
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Comfort
Cleanliness
Temperature
Noise Level
Decor
Fair
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Average
Row 0, Column 1
Good
Row 0, Column 2
Very Good
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Excellent
Row 0, Column 4
Fair
Row 1, Column 0
Average
Row 1, Column 1
Good
Row 1, Column 2
Very Good
Row 1, Column 3
Excellent
Row 1, Column 4
Fair
Row 2, Column 0
Average
Row 2, Column 1
Good
Row 2, Column 2
Very Good
Row 2, Column 3
Excellent
Row 2, Column 4
Fair
Row 3, Column 0
Average
Row 3, Column 1
Good
Row 3, Column 2
Very Good
Row 3, Column 3
Excellent
Row 3, Column 4
Fair
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Average
Row 4, Column 1
Good
Row 4, Column 2
Very Good
Row 4, Column 3
Excellent
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8
How long did you wait before being attended to?
Less than 15 minutes
15 - 29 minutes
More than 30 minutes
9
Would you return or recommend our facility to others?
Yes
No
10
Overall, how would you rate the services provided by the:
Fair
Average
Good
Very Good
Excellent
Therapist
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Receptionist
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Therapist
Receptionist
Fair
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Average
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Good
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Very Good
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Excellent
Row 0, Column 4
Fair
Row 1, Column 0
Average
Row 1, Column 1
Good
Row 1, Column 2
Very Good
Row 1, Column 3
Excellent
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11
How did you find out about Doctors Hospital Rehabilitation?
Word of Mouth
Social Media
Radio
Newspaper
Television
Physician Referral
Other
12
Would you be interested in submitting a testimonial about your experience at Doctors Hospital Rehabilitation Services?
YESNO
13
Please feel free to make any suggestions for improvements and/or comments on the overall care and service provided.
Huge
Large
Normal
Small
Ok
Ok
14
Name
First Name
Last Name
15
Address
Street Address
Street Address Line 2
Settlement/City
Island
P.O. Box
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
16
Phone Number (H)
Please enter a valid phone number.
17
Phone Number (W)
Please enter a valid phone number.
18
Email
example@example.com
Should be Empty: