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Creekside Physiotherapy
204-832-6603
Physiotherapy Works!
204-942-2463
Portage Physiotherapy
204-239-4730
Sage Creek Physiotherapy
204-253-6768
Quarry Physio - Stonewall
204-467-9101
Quarry Physiotherapy - Gimli
204-642-5353
Quarry Physiotherapy - Arborg
204-376-2406
Quarry Physiotherapy - Gillam
204-652-2245
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» INTAKE SURVEY
Question marked with * are mandatory.
INTAKE SURVEY
Q1.
Which location did you visit *
Creekside Physiotherapy
Physiotherapy Works!
Portage Physiotherapy
Sage Creek Physiotherapy
Quarry Physiotherapy - Stonewall
Quarry Physiotherapy - Gimli
Quarry Physiotherapy - Arborg
Quarry Physiotherapy - Gillam
Q2.
Which service did you attend? *
Physiotherapy
Massage Therapy
Chiropractor
Sports Medicine
Nursing Foot Care
Athletic Therapy
Personal Training/Kinesiology
Dietitian
Q3.
How did you hear about our clinic *
Previous patient
Physician
Word of mouth
Advertising
Website
Facebook
Instagram
Yellow Pages
Other
If Other, how did you hear about us?
Q4.
What was your first impression of our clinic
Q5.
How quickly did we schedule your first visit *
Poor
Fair
Average
Good
Excellent
Q6.
Friendliness of the staff who greeted you and took care of you at your first visit *
Poor
Fair
Average
Good
Excellent
Additional comments
Q7.
Courtesy of Support Staff in treatment and gym area *
Poor
Fair
Average
Good
Excellent
Additional comments
Q8.
Was your length of wait before going into the treatment area acceptable *
Yes
No
If no, please explain:
Q9.
Appearance and cleanliness of clinic *
Poor
Fair
Good
Very Good
Excellent
Comments:
Q10.
How well were your insurance questions answered *
Poor
Fair
Average
Good
Excellent
Not applicable
Additional comments
Q11.
Your Therapist* *
Strongly Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree
1. Understands my feelings and concerns
2. Was knowledgeable and clearly explained my condition/injury to me
3. Was skillful in treating me
4. My appointment was appropriate in length
5. I was satisfied with my appointment
Other comments
Q12.
Would you recommend our clinic to friends and relatives *
yes
no
If no please tell us why:
Q13.
Add other comments or insights below that could help us improve your first experience with our clinic
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