Patient Survey

Patient Information

Patient Age

Patient Gender

Male

Female

How did you hear about Comprehensive Therapy:

If other is selected, please specify:

Please rate Comprehensive Therapy on the following

5 = Excellent 1 = Poor

Attended to in a timely manner:

Courtesy / Attitude of Employees:

Patient Care:

Clinic Appearance / Cleanliness:

Relationship with Staff:

Relationship with Therapists:

Rate Comp. Therapy vs. other health care experiences:

Overall Experience:

General Health Care Questions:

5 = High Priority 1 = No Concern

Importance of Comp. Therapy being in your Health Plan:

Rating of your companies Health Plan:

Comfort with the Internet for health questions:

What would be the earliest appointment you would schedule:

What would be the latest appointment you would schedule:

Would you be interested in any of the following programs: (Check all that apply)

If other is selected, please specify: