Patient Intake Survey

First Name: *Required
Last Name: *Required
Email Address (For future info at HPT): *Required
1. The telephone was answered in a courteous manner	Very Good	Good	Fair	Poor
2. Appointment/Insurance details were explained	Very Good	Good	Fair	Poor
3. I felt welcomed by the staff when I arrived to the practice	Very Good	Good	Fair	Poor
4. I felt my therapist listened carefully to my concerns	Very Good	Good	Fair	Poor
5. My questions were answered	Very Good	Good	Fair	Poor
6. I was part of goal setting	Very Good	Good	Fair	Poor
7. The treatment plan was explained & I could understand it	Very Good	Good	Fair	Poor
8. I had confidence in my therapist's ability	Very Good	Good	Fair	Poor
9. Follow-up appointments were taken care of efficiently	Very Good	Good	Fair	Poor
10. My experience program was at an appropriate level	Very Good	Good	Fair	Poor
11. I feel that the treatment has been beneficial	Very Good	Good	Fair	Poor
12. I felt the facility was clean & well maintained	Very Good	Good	Fair	Poor
13. I was given a home program which is helpful	Very Good	Good	Fair	Poor
14. I did not mind being treated by different therapists	Very Good	Good	Fair	Poor
15. What would we do to make this a better experience?
16. You comments:
17. Would you recommend Hesperia Physical Therapy & Aquatics to your Doctor, Family and Friends?	Yes	No	Maybe
18. May we use any of your comments for advertising purposes?	*Required