Dear Patient,

Many thanks for choosing Sitka Physical Therapy for your recent course of treatment; we hope to have met your expectations and assisted you in your path to wellness. Because we strive to deliver the best possible physical therapy service, we are interested in learning from you how we might improve or enhance our services. Please take a moment to complete this online questionnaire. You need only include your name if you wish to do so. Thank you!

Name (optional) Date

Problem for which you were treated


Please rate your degree of satisfaction with each of the following statements.

1 = strongly disagree
2 = disagree
3 = neither agree nor disagree
4 = agree
5 = strongly agree
0 = if you have no opinion on the subject

Please select the appropriate number and include comments for further explanation.

1. Physical therapy care was provided in a timely manner following my injury

2. It was easy to schedule all of my physical therapy appointments

3. I was seen promptly when I arrived for treatment

4. I was satisfied with the facility and its appearance

5. My physical therapist was courteous and attentive

6. The thoroughness of the examination was sufficient

7. My therapist adequately explained my diagnosis and treatment options

8. I was satisfied with the treatment provided by my physical therapist

9. The instructions my physical therapist gave me were helpful

10. The outcome of treatment prescribed was favorable

11. My home program (print & E-mail) is clearly presented and easy to follow

12. The cost of physical therapy services was reasonable

13. My expenses and insurance coverage was properly explained

14. I would recommend Sitka Physical Therapy to family or friends

15. I would return to this facility if I required physical therapy care in the future


Would you like a follow-up phone call in 2 weeks to discuss your continued progress??

If yes, at which number would you like to be reached?


Again, thank you for choosing Sitka Physical Therapy and for your time in completing this questionnaire.

Remember that we are always available to discuss questions or concerns over the phone, or you may schedule an appointment; just call (907) 747 4559.

Copyright @2005-2012 Sitka Physical Therapy, Site Design Andaleon & Associates

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