Baxter & Walsh Physical Therapy

Baxter & Walsh Physical Therapy

2237A Wantagh Ave 8 Saxon Avenue

Wantagh, NY 11793 Bay Shore, NY 11706

516-826-0116 631-206-2989

Karen Baxter Furno, P.T., D.P.T.

Monica Walsh Caraciolo, P.T., D.P.T. LIKE US ON FACEBOOK! WWW.FACEBOOK.COM/BAXTERWALSHPHYSICALTHERAPY

At Baxter & Walsh Physical Therapy, we are committed to providing the utmost quality care in a comfortable yet professional environment. Please take the time to complete this survey so that we can assure that we are providing care to the best of our ability.

Thank you very much for your feedback.

1.  Your age: ______years

2.  Your sex: ____ Male ____ Female

3.  How did you learn about this facility? (check all that apply)

___ Physician ___ Insurance Company ___ Relative ___ FDNY

___ Friend ___ Former Patient ___ Location ___ HSS

___Telephone Book ___ Advertisement ___ Other (please indicate) ______

4.  Was this your first experience with physical therapy? ____ Yes ____No

5.  Was this your first experience with this facility? ____ Yes ____No

6.  Please check the location of the problem for which you received physical therapy (check all that apply)

___ Neck ___ Hip ___ Lower Back ___Pregnancy

___ Shoulder ___ Elbow ___ Hand ___ Hand/Wrist

___ Foot ___ Foot/Ankle ___ Knee Other (please specify)______

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)

7.  My goals for physical therapy were met. _____

8.  My physical therapist was courteous. _____

9.  All other staff members were helpful. _____

10.  The office scheduled appointments at convenient times. _____

11.  I was satisfied with the treatment provided by my physical therapy. _____

12.  My first visit for physical therapy was scheduled quickly. _____

13.  It was easy to schedule visits after my first appointment. _____

14.  I was seen promptly when I arrived for treatment. _____

15.  The location of the facility was convenient for me. _____

16.  Parking was available for me. _____

17.  My physical therapist understood my problem or condition. _____

18.  The instructions my physical therapist gave me were helpful. _____

19.  I would recommend this facility to family and friends. _____

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

21.  Overall, I was satisfied with my experience with physical therapy. _____

Additional Comments or Suggestions:

Optional Name:______