Patient Feedback

1. Your name

2. Physiotherapist's name

3. Patient's name (if different)

4. Where did you find out about us?

5. How positive was your experience when you first made contact with us?
—Please choose an option—1 - very poor2 - poor3 - average4 - good5 - very good

6. How long did you have to wait for your first appointment?
—Please choose an option—Less than 24 hours1-2 days3-7 daysOver 1 week

7. How convenient were your appointment times?
—Please choose an option—1 - very poor2 - poor3 - average4 - good5 - very good

8. How good was the rapport between you and your physio?
—Please choose an option—1 - very poor2 - poor3 - average4 - good5 - very good

9. If you would prefer to be seen by another physio for your follow up appointments, we can arrange for you to be seen by someone more suited for you

No thanks, I am happy with my current physioYes please, contact me about a possible therapist change

10. How well did the physio explain your treatment options at the end of your 1st assessment?
—Please choose an option—1 - very poor2 - poor3 - average4 - good5 - very good

11. How well did the physio involve you in setting treatment goals and/or answering your questions?
—Please choose an option—1 - very poor2 - poor3 - average4 - good5 - very good

12. How clear were your instructions for your home exercises and/or using equipment?
—Please choose an option—1 - very poor2 - poor3 - average4 - good5 - very good

13. How would you rate our service overall?
—Please choose an option—1 - very poor2 - poor3 - average4 - good5 - very good

14. We welcome any comments and suggestions. Please let us know your thoughts in the box below

15. Would you mind us using your responses to promote our service?

Yes you can use my responses but please do not use my nameYes you can use my responses and I don't mind you using my nameNo I'd rather you didn't use my responses