Patient Satisfaction Survey

Patient Satisfaction Survey
Full Name*

First NameLast Name
Phone Number*
E-mail
example@example.com
The facility was equipped to meet my needs.*

Strongly AgreeAgreeDisagreeStrongly DisagreeNot Applicable
The staff was professional, courteous and knowledgeable.*

Strongly AgreeAgreeDisagreeStrongly DisagreeNot Applicable
My therapist explained my condition to me in a way I could understand.*

Strongly AgreeAgreeDisagreeStrongly DisagreeNot Applicable
I feel I made meaningful progress during the course of physical therapy.*

Strongly AgreeAgreeDisagreeStrongly DisagreeNot Applicable
I am satisfied with the overall quality of my physical therapy care.*

Strongly AgreeAgreeDisagreeStrongly DisagreeNot Applicable
I would recommend this facility to family and friends.*

Strongly AgreeAgreeDisagreeStrongly DisagreeNot Applicable
After discharge from therapy I plan to continue exercising: (please mark all that apply)*

At the Center for Balance, Mobility and Wellness as a fitness memberAt home with a home exercise programAt the local Senior Center or Council on AgingAt another gym or fitness facilityI am not planning to continue to exercise
The Center for Balance, Mobility and Wellness is a non-profit organization which gratefully welcomes donations for the purposes of maintaining, improving, and expanding our services and facility. Although the Center is a Gordon College program, it is financially self-sustaining. Charitable gifts and donations are therefore greatly appreciated. We hope you will consider contributing. If you choose to give, your tax-deductible donation will directly support the Center and will not be used for general purposes of the College.

With your help the Center will continue to make a positive impact on the health and wellness of residents of the North Shore and be a resource for the local medical community.
I would like to make a tax-deductible donation to the Center for Balance, Mobility and Wellness.*

YesNo
I am willing to receive future communications from the Center (e.g. educational seminars, newsletters, promotional materials, donation opportunities.)*

YesNo, please remove my name from all communication lists
Should be Empty: