PATIENT QUESTIONNAIRE & OUTCOME SURVEY

Dear Valued Patient,

The staff at EXCEL Therapy Specialists is pleased to have been able to serve you. We appreciate all feedback we receive from patients and attempt to integrate your suggestions to improve our practice. In order to serve you better, we would appreciate you taking a few moments to complete this questionnaire. Please return it to the receptionist by mail, fax, or complete the questionnaire on our website at www.exceltherapyspecialists.com.

How would you rate the following based upon the key below:

1 = Excellent 2 = Very Good 3 = Good 4 = Fair 5 = Poor

Please circle the corresponding number:

1. The thoroughness of your initial physical therapy evaluation? 1 2 3 4 5

2. The professionalism and knowledge of your physical therapist? 1 2 3 4 5

3. The punctuality of the services you received? 1 2 3 4 5

4. Your physical therapist’s communication with your physician? 1 2 3 4 5

5. The overall quality of your physical therapy treatment program? 1 2 3 4 5

6. The professionalism, efficiency, and supervision of our physical

therapist support staff while performing your exercise program? 1 2 3 4 5

7. The professionalism, promptness and courtesy of our receptionist? 1 2 3 4 5

8. The ease with which you were able to schedule your appointments? 1 2 3 4 5

9. The professionalism and helpfulness of our business office personnel? 1 2 3 4 5

10. The clarity of the explanation of your insurance coverage? 1 2 3 4 5

11. The clarity of our billing procedures and statements? 1 2 3 4 5

12. Assistance with our billing procedures or insurance questions? 1 2 3 4 5

13. The overall quality of all services received at Excel Therapy Specialists? 1 2 3 4 5

14. Your overall experience at Excel Therapy Specialists? 1 2 3 4 5

15. How do you feel now, at the completion of your physical therapy program?

1) painfree/completely recovered 2) much improved

3) slightly improved 4) unchanged 5) worse 1 2 3 4 5

16. Would you return to Excel for care in the future or refer a friend/family member? yes no

17. Additional comments: ____________________________________________________________

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THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE!

Please return survey to:

EXCEL Therapy Specialists, LLC

Attention: Customer Service

2424 E. 21st Street, Suite 400

Tulsa, OK 74114

Or fax survey to: (918) 743-9234