Patient Survey

Patient Survey:

* Indicates required field

How did you hear about In Motion Physical Therapy? *

Physician Family/Friend Insurance Advertisement Drive-by Other

If Other please specify: *

How did you schedule your first appointment? *

Phone In Person Through my Doctor Through my Insurance Other

If Other please specify: *

What was the purpose of your visit (check all that apply)? *

Head/Neck Mid/Lower Back Shoulder Hand/Wrist/Elbow Hip/Knee Foot/Ankle Gait/Balance Posture/Flexibility

Cleanliness and general appearance of facility: *

Very Clean and Welcoming Somewhat Clean and Welcoming Not so Clean nor Welcoming

Who was the Physical Therapist you saw for your initial evaluation? *

Joanna Frantz, PT, MSPT, DPT Kirsten Heath, PT, DPT, OCS Other

If Other, please specify: *

For each of the following questions, select the answer that best describes your experience.

How easy was it to make your first appointment? *

How easy was it to make your subsequent appointments? *

Front office staff was professional, courteous, and friendly. *

The helpfulness of the staff that assisted you with billing or insurance. *

The Physical Therapist was courteous and friendly. *

During the evaluation the Physical Therapist explained my treatment and plan and/or gave me future goals. *

The Physical Therapist gave me home exercises and proper instructions at the initial evaluation. *

The Physical Therapist was able to answer my questions about my condition. *

The Physical Therapist explained things in a way I could understand. *

How would you rate your overall experience at In Motion Physical Therapy? *

Other Comments *

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