Questionnaire

Dear Patient:

Thank you for allowing ADAPT to be a part of your rehabilitation.

We hope your Physical Therapy visits were a positive experience and that you would recommend us to your family or friends.

Please take a few moments AFTER YOU HAVE BEEN DISCHARGED FROM THERAPY to complete.

Do Not Hesitate to call our office if you have any questions or concerns.

Sincerely,
The Staff of ADAPT

Name*
First Last
Courtesy and helpfulness of office staff.*
- Poor - 1
- Fair - 2
- Good - 3
- Excellent - 4
Ease of scheduling appointments.*
- Poor - 1
- Fair - 2
- Good - 3
- Excellent - 4
Therapist knowledge about your condition and how to treat it.*
- Poor - 1
- Fair - 2
- Good - 3
- Excellent - 4
Explanation about what will be done during treatment.*
- Poor - 1
- Fair - 2
- Good - 3
- Excellent - 4
Did your therapist use plain language (laymen terms) during your treatment?*
- Poor - 1
- Fair - 2
- Good - 3
- Excellent - 4
Your care overall.*
- Poor - 1
- Fair - 2
- Good - 3
- Excellent - 4
Comfort and cleanliness of the facility.*
- Poor - 1
- Fair - 2
- Good - 3
- Excellent - 4
Comments
Phone
If you would like someone to contact you regarding any concerns please include your phone number.

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Adapt Physical Therapy complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Adapt Physical Therapy cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-541-773-2999.