New Hampshire Hand Therapy Center, Inc.

The staff at New Hampshire Hand Therapy Center continually strives for excellence in care. In order to improve our services, we ask that you take a few minutes to complete this survey about your recent therapy experience in our clinic because your opinion matters to us.

*Diagnosis:
*Referring Physician:
*Primary Therapist:
*Insurance Company:
*Discharge Date:
Name (Optional):
*E-Mail Address:

	Unsatisfied	Below Average	Satisfied	Above Average	Excellent
1. Were you scheduled for therapy in a timely way?
2. Were your therapy appointments scheduled at a convenient time for you?
3. Was the office staff courteous and helpful?
4. Was your therapist professional and caring?
5. Please rate your overall satisfaction with your treatment.

6. Did you receive a thorough evaluation?	Yes		No
7. Were your therapy goals and treatment explained clearly?	Yes		No
8. Did you participate regularly in a home program prescribed by your therapist?	Yes		No
9. Did you benefit from therapy?	Yes		No		Somewhat
10. Would you recommend our clinic to others?	Yes		No		Uncertain
Additional Comments: