Q1. During Your Visits *

	Poor	Fair	Good	Very Good	Excellent
1. Courtesy of staff at the front desk
2. Length of wait before going to the treatment area
3. Comfort and pleasantness of treatment area

Q2. Your Therapist *

	Strongly Disagree	Somewhat Disagree	Somewhat Agree	Agree	Strongly Agree
1. Can view things from my perspective (see things as I see them)
2. Understands my emotions, feelings and concerns
3. Was knowledgeable and clearly explained my condition/injury to me
4. Was skillful in treating me

Q3. Appointment Setting *

	Poor	Fair	Good	Very Good	Excellent
1. Ease of scheduling your appointments
2. Courtesy of person who scheduled your appointment

Q4. Your likelihood of recommending our clinic to your friends and relatives *

Q5. What is the most important improvement we can make?

Q6. Add any other comments below

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