Stewart Physical Therapy

Q.1

Where did you receive your treatment today?

Q.2

Please rate from 1 Lowest to 5 Highest *

	1	2	3	4	5
Were you greeted with a friendly smile when you arrived?
Was the facility clean, neat and prepared when you arrived?
Did your therapist provide excellent treatment services today?
Was your experience today of great value for you?
Was the staff considerate of your time and sensitive to your condition?

Were you greeted with a friendly smile when you arrived?

1 2 3 4 5

Was the facility clean, neat and prepared when you arrived?

1 2 3 4 5

Did your therapist provide excellent treatment services today?

1 2 3 4 5

Was your experience today of great value for you?

1 2 3 4 5

Was the staff considerate of your time and sensitive to your condition?

1 2 3 4 5

Q.3

What is the best time between 7:00AM-7:00PM for you to receive treatment?

Q.4

Additional Comments

Q.5

What is the name of your primary treating therapist?