Evaluation
It is important that we continually evaluate our services so that we can develop and improve. Please answer the following questions regarding your health and your assessment experience.
Date
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Name
*
First Name
Last Name
Please tell us your main symptoms/reasons for attending physiotherapy or rehabilitation.
Balance
Walking
General mobility issues
Upper limb function
Pain
Muscle weakness
Recovery from surgery
Sports injury
Lower limb function
Other
On a scale of 1-10 please tell us how much the reasons given above affect your day to day life?
*
Barely affect you
1
2
3
4
5
6
7
8
9
Really affect you
10
1 is Barely affect you, 10 is Really affect you
On a scale of 1-10 please rate your OVERALL feeling of:
Physical wellbeing
*
Very Bad
1
2
3
4
5
6
7
8
9
Great
10
1 is Very Bad, 10 is Great
Emotional/mental wellbeing
*
Very Bad
1
2
3
4
5
6
7
8
9
Great
10
1 is Very Bad, 10 is Great
On a scale of 1-10 please rate the following:
Your welcome upon arriving at the Centre
*
Very Bad
1
2
3
4
5
6
7
8
9
Great
10
1 is Very Bad, 10 is Great
Your experience with your physiotherapist or rehabilitation specialist
*
Very Bad
1
2
3
4
5
6
7
8
9
Great
10
1 is Very Bad, 10 is Great
Submit
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