Call Us
Perry Hall Shopping Center
4337 Ebenezer Road
Perry Hall, MD 21236
(410) 529-3303
Home
Question marked with * are mandatory.

Discharge Survey

We are committed to bring you clinical excellence and a highly positive experience in our office. As part of our effort to keep on that track, we ask that you, please, complete the following brief survey.

Your responses are totally confidential. 

We thank you for the value you add to our practice by your participation!

Q1. My therapist was: *
Q2. During Your Visits *
  Strongly Agree Agree Neutral Disagree Strongly Disagree
The front desk staff was courteous and efficient.
Overall, the clinic was comfortable and the surroundings were pleasant and clean.
Q3. Your Therapist: *
  Strongly Agree Agree Neutral Disagree Strongly Disagree
Was willing to listen to your questions.
Was knowledgeable and clearly explained your condition/ injury to you.
Clearly explained the instructions for your home exercise program.
Comment (describe good or bad experiences)
Q4. Future Visits *
  Strongly Agree Agree Neutral Disagree Strongly Disagree
In the future, if you are in need of Physical Therapy, you will return to Active Life & Sports Physical Therapy.
In the future, if you return to Active Life & Sports Physical Therapy, you will request the same Physical Therapist.
Q5. Recommendations for Improvements *
  Strongly Agree Agree Neutral Disagree Strongly Disagree
You would recommend changes for improvement within this Physical Therapy clinic.
Suggested recommendations:
Q6. How likely are you to refer us to your friends, family and colleagues if they are in need of Physical Therapy in the future? Scale - (1) Highly Unlikely - (10) Highly Likely *
 
 
 
 
 
 
 
 
 
 
Q7. Your favorite part of your experience at Active Life & Sports Physical Therapy was:
Please enter the following text in the box
Sample