How Are We Doing?

Please take a few minutes to fill out this survey on the timeliness and quality of the service you received today. Rancho Physical Therapy welcomes your feedback and your answers will be kept confidential. Thank you for your participation.

General Patient Information

In general, what is the quality of your health?
Outstanding Good Some chronic issues Poor

How would you rate our concern for your privacy?
Outstanding Good Adequate Needs improvement Poor N/A

How often have you visited Rancho Physical Therapy within the past year?
First visit 2 to 5 visits 6 or more visits

Scheduling Your Appointment

Did you schedule an appointment by phone or did you walk in?
Phone Walk In

How satisfied were you with your ability to get this appointment as soon as you wanted it?
Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied

How easy was it to make an appointment by telephone?
Very Easy Easy Neutral Difficult Very Difficult

How long did you wait to speak to a scheduling staff member?
0 to 2 minutes 3 to 5 minutes 5 to 7 minutes Longer

Was the person who scheduled your appointment courteous and helpful?
Very Courteous Courteous Neutral Not Courteous Rude

Day of Your Appointment

How would you rate the courtesy of the staff at the reception desk?
Very Courteous Courteous Neutral Not Courteous Rude

How long did you wait in the reception area beyond your scheduled appointment time?
0 to 5 minutes 5 to 20 minutes 20 to 40 minutes Longer

How long did you wait in the exam room before the therapist arrived?
0 to 5 minutes 5 to 20 minutes 20 to 40 minutes Longer

Which department(s) did you visit during your appointment?
Physical Therapy Occupational Therapy Speech Therapy Other

The Support Staff

How would you rate the competence of the aide who helped you?
Outstanding Good Adequate Needs improvement Poor N/A

How would characterize the concern that the aide showed for your problem?
Outstanding Good Adequate Needs improvement Poor N/A

Did the aide respond to your requests within a reasonable period?
Yes No N/A

The Physical Therapist / Therapist Assistant

Were you able to see the therapist of your choice?
Yes No N/A

Did you feel that your therapist spent an adequate amount of time with you?
Yes No N/A

Mark the boxes that characterize the demeanor of your therapist:
Attentive Concerned Friendly Distracted Rushed Inconsiderate

How would you rate the competence of your therapist?
Outstanding Good Adequate Needs improvement Poor N/A

Did you feel that your therapist�s examination was thorough?
Yes No N/A

Please rate the clarity of the therapist�s explanation of your treatment and home exercise plan:
Outstanding Good Adequate Needs improvement Poor N/A

How well did your therapist include you in healthcare decisions?
Outstanding Good Adequate Needs improvement Poor N/A

Were your questions answered to your satisfaction?
Yes No N/A

Would you recommend this facility and its staff to your family and friends?
Yes No N/A

The Facility

How would you rate the cleanliness of the exam room/treatment area?
Outstanding Good Adequate Needs improvement Poor N/A

How would you rate the cleanliness of the pool and surrounding area?
Outstanding Good Adequate Needs improvement Poor N/A

How would you rate the cleanliness of the restrooms/locker rooms?
Outstanding Good Adequate Needs improvement Poor N/A

How would you rate the overall cleanliness of the clinic?
Outstanding Good Adequate Needs improvement Poor N/A

Additional Feedback

Please list any areas in which our service could be improved:

Please share any additional comments:

Personal Information

Providing the following information is optional.

First Name:		Last Name:
Address:		City:
State:	Zip:	Phone:

Gender:

Age:

Would you like someone to contact you regarding your responses on this survey?
Yes No

I was treated at the following clinic:

Please provide the name of your therapist: