We are interested in your comments about our facility and your treatment program. Please take a few moments to complete the following survey.

   
  Your first name:
  Your last name:
  Spine and Sport location where you were treated:
   
1. Friendliness & efficiency of the front desk:
 
Excellent
Very Good
Good
Adequate
Poor
   
2. Friendliness & effectiveness of the therapist:
 
Excellent
Very Good
Good
Adequate
Poor
   
3. Any Recommended improvements in the facility?
 
   
4. How did you feel about the following aspects of your treatment program?
 
Number of Visits:
Fine as is Too many visits Not enough visits
Clinic time per visit:
Fine as is Too much time Not enough time
Duration of program:
 Fine as is Too long Not long enough
   
5. Did the availability of appointments times meet your needs?
  Yes
  No
   
6. Did the program meet your personal objectives?
  Yes
  No
   
7. Were the program objectives explained to you?
  Yes
  No
   
8. Would you recommend our program to someone else?
  Yes
  No
   
9.

Compared to when you were first seen at this clinic, is your pain?
  Better
  Same
  Worse
   
10. Do you feel your pain is currently:
  Abolished
  Intermittently pain-free
  Lessened
  No better
   
11. How well are you able to do your daily activities?
  Normal
  Modified partially
  Modified severely
  Unable
   
12. Have you had surgery?
  Yes No
  If yes when? (mm/dd/yyyy)
  If yes did the surgery help? Yes No
   
13. Did you receive other treatments before attending therapy here?
  Yes No
  If yes what treatments?
  If yes did the treatments help? Yes No
  Did you receive other treatments during or after attending therapy at our location?
  Yes No
  If yes when? (mm/dd/yyyy)
  If yes did the treatments help? Yes No
   
14. Were you working full duty at the start of your therapy program?
  Yes No
  What is your current work status?
  Return to full duty Modified duty Not returned to work Other
   
15. Are you currently participating or do you plan to participate in an exercise program?
  Yes No
   
  Please note any other comments you feel would help improve our clinic. Thank you!
 
   
  Optional:
 
Address:
*
City:
 St. Zip:
  Can we contact you via email should we have any questions that could help improve our patient care? Yes No
  E-mail address*:
*Any e-mail address provided will be held in strict confidence and not shared with anyone or any company outside the Spine and Sports companies.
 
  THANK YOU!