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Patient Satisfaction Survey

Dear Patient:

At Back On Track, we strive to deliver the best possible physical therapy services. We are interested in learning from our patients how we might improve or enhance our services. Please take a few moments to fill out this questionnaire. Any additional information is welcome in the comments section at the end of the questionnaire. All questions, including your name, are voluntary. Thank you very much for your feedback.

First Name: Last Name:

Email Address:

1. Was this your first experience with Back On Track? Yes No

2. How long have you been with Back On Track? (approx visits or weeks)

3. Are you being discharged? Yes, This Week No, Not Yet

4. Who was your therapist?

5. Which Back On Track location did you visit?

Brookline (1180 Beacon St) Brookline (1269 Beacon St)
Cambridge Danvers Newton Waltham

Please rate your degree of satisfaction with each of the following statements:

6. My physical therapist and all staff have been courteous.

7. I have been satisfied with the treatment provided by my P.T.

8. It has been easy to schedule my appointments.

9. My bills were accurate.

10. I would recommend Back On Track to my family or friends.

11. If I had to, I would pay for physical therapy services myself.

12. Overall, I have been satisfied with my experience at Back On Track.

13. As a percentage, what is your level of improvement? %

14. Are your goals being fully met? Yes Mostly Partially No

Comments:

BEDFORD • BROOKLINE • CAMBRIDGE • DANVERS • NEWTON • WALTHAM

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