Frederick Sport and Spine Clinic, Inc.

Frederick
84 Thomas Johnson Court, Suite B
Frederick, MD 21702
301.662.8541

Middletown
205B South Church Street
Middletown, MD 21769
301.371.8121

You recently completed your rehabilitation with us at Frederick Sport and Spine Clinic. Your input enables us to ensure our patients receive the best rehabilitation service possible. Please take a moment to fill out this satisfaction survey regarding your experience and return it once it is completed. Thank you!

YOUR THERAPIST	Excellent	Good	Fair	Poor	Unacceptable
Freindly ad Courteous Behavior
Professional Behavior
Communication Regarding your Injury/Condition
Response to Your Concerns
Timely Attention to Your Needs
Overall Quality of Your Therapist

SUPPORT STAFF	Excellent	Good	Fair	Poor	Unacceptable
Friendly and Courteous Behavior
Professional Behavior
Communication Regarding Your Treatment
Appointment Scheduling
Timely Attention to Your Needs
Explanation of Billing/Payment
Overall Quality of Support Staff

CLINIC/FACILITIES	Excellent	Good	Fair	Poor	Unacceptable
Condition/Cleanliness of Clinic
Furnishings and Décor
Parking Convenience
Location of Clinic
Overall Comfort and Appeal

OVERALL IMPRESSION	Excellent	Good	Fair	Poor	Unacceptable
Overall Quality of This Clinic
Satisfaction with Your Treatment

If given the opportunity, would you recommend this clinic to others?	Yes	No
Have you recommended this clinic to others?	Yes	No

How many times have you been seen for your most recent injury/condition?
1 visit	2-4 visits	5-10 visits	11 or more visits

Were you seen at your scheduled time?

Yes

Does our clinic offer sufficient hours?	Yes	No
If not, please suggest additional hours that would better suit your needs:

Were goals set for your treatment?	Yes	No
Were these goals clearly defined and understandable?	Yes	No
Did your therapist encourage your involvement in goal setting?	Yes	No
Were your goals met?	Yes	No

Did your therapist provide a home program?	Yes	No
Was your home program clearly defined?	Yes	No
Were you offered written materials?	Yes	No
Have you continued to do your home program?	Yes	No

What did you like best about our clinic?

What would you recommend we do to improve the quality of our clinic?

Which factors influenced your decision to come to this clinic? (Check all that apply).
Physician Referral	Therapist Referral
Convenient Location	Yellow Pages/Advertising
Insurance Referral	Employer Referral
Friend/Family Referral	Case Manager/Rehab Nurse
Used Clinic Previously	Other (enter below)

OPTIONAL
Name:
Phone: