Patient Assessment Form

The Center for Total Back Care constantly strives to provide the highest quality physical therapy and chiropractic care and are always looking for ways to improve. Your feedback is important to us.

1. Personal Info

2. Our Services

3. Feedback

Full NameWhy were you referred to physical therapy/chiropractic (chief complaint or diagnosis)?Were your insurance benefits explained to you on or before your first visit?

Yes

Can't remember

On average, how long did you have to wait to see your therapist after you arrived for your scheduled visit?

Less than 10 minutes

10-15 Minutes

More than 15 minutes

How satisfied were you with the care provided by your physical therapist/chiropractor?

Very satisfied

Somewhat satisfied

Somewhat dissatisfied

Dissatisfied

If dissatisfied, what were you dissatisfied with?After receiving care, do you feel your condition improved?

Greatly Improved

Somewhat Improved

Not Improved

Worse

Would you consider referring a friend or family member to our practice?

Yes

What could we improve?Have you any specific sucesses as a result of your treatment that you would like to share?May we share your responses? (We will not share your personal information)

Yes

Services

Physical Therapy

Chiropractic Care

MedX Specific Spinal Testing and Rehabilitation

VAX-D Non-Surgical Spinal Disc Decompression Therapy

Dry Needling

Spine Fitness Membership Program

Areas Served

Ahwatukee

Chandler

Gilbert