Physiotherapy Assessment Form

Physiotherapy Assessment Form
This Physical Therapy Clinic cares about your feedback. Please take a moment and fill out this form to help us improve.
First Contact & Registration

Please indicate your level of agreement with the following statements.

Rows	Totally Agree	Agree	Not Sure	Disagree	Totally Disagree
Administrative staff was reachable during business hours.
I was able to make an initial appointment.
Insurance issues and payments were explained clearly.
All phone calls were returned.

Please indicate your level of agreement with the following statements.

Rows	Totally Agree	Agree	Not Sure	Disagree	Totally Disagree
Administrative staff was professional and friendly.
I didn't wait too long for the first evaluation.
The physical therapist introduced him/herself to me.
The physical therapist was professional and friendly.
My injury/problem was explained clearly to me.
I was asked what I wanted to accomplish in physical therapy.
The plan of the physical therapy was stated clearly.
The physical therapist gave me some home exercises with instructions.

Please indicate your level of agreement with the following statements.

Rows	Totally Agree	Agree	Not Sure	Disagree	Totally Disagree
My every appointment began on time.
I was on time for my appointments.
I received enough attention from the staff.
My physical therapist updated my home exercises regularly.
I was informed about my progress regularly.
I did all of the things that my therapist suggested for my treatment.
My treatment process made me feel good.
My physical therapist communicated well and regularly with my physician.

Please indicate your level of agreement with the following statements.

Rows	Totally Agree	Agree	Not Sure	Disagree	Totally Disagree
I was informed about how I progressed with my therapy from my first visit to the last.
I was given instructions for improving my condition at the last visit.
I recommend this Physical Therapy Clinic to friends and family.
I will encourage my physician to refer more people to this Physical Therapy Clinic.

Comment on this section.
How would you rate your percentage of improvement?
How would you rate your overall experience?

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1 is Poor, 10 is Perfect
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