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Question marked with * are mandatory.

INTAKE SURVEY

Q1. Which location did you visit *
Q2. Which service did you attend? *
 
 
 
 
 
 
 
 
Q3. How did you hear about our clinic *
 
 
 
 
 
 
 
 
 
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 *
 
 
 
 
 
Q6. Friendliness of the staff who greeted you and took care of you at your first visit *
 
 
 
 
 
Additional comments
Q7. Courtesy of Support Staff in treatment and gym area *
 
 
 
 
 
Additional comments
Q8. Was your length of wait before going into the treatment area acceptable *
 
 
If no, please explain:
Q9. Appearance and cleanliness of clinic *
 
 
 
 
 
Comments:
Q10. How well were your insurance questions answered *
 
 
 
 
 
 
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 *
 
 
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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