Q1. How did you hear about us?

Other	Doctor referral	Previous patient
Friend/Family	Website	Yellow pages

Q2. Physiotherapy visit feedback

	Not Satisfied	Somewhat Satisfied	Very Satisfied	Couldn't be happier
Professionalism
Friendliness
Amount of information given
Billing policy
Quality of treatment

Q3. How satisfied were you with the clinic environment?

	Not Satisfied	Somewhat Satisfied	Very Satisfied	Couldn't be happier
Clinic layout
Patient privacy
Clinic cleanliness
Clinic location

Q4. How satisfied were you with the following components of your physiotherapy?

	Not Satisfied	Somewhat Satisfied	Very Satisfied	Couldn't be happier
Clinic cleanliness
Clinic layout
Patient privacy
Initial assessment
Education about the injury
Physiotherapist's competency
Friendliness of staff
Attentiveness of staff

Q5. How would you rate your overall physiotherapy experience? (0=worst, 10=best)

Q6. Would you recommend Martindale Physiotherapy to family or friends?

Q7. Anything other comments?

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