COLLEGE OF PHYSICAL AND RESPIRATORY THERAPY

Carlatan, City of San Fernando, La Union

Questionnaire

Instruction: Please fill up the blanks completely and honestly. Put a check () mark on
the boxes accordingly

I. Profile
a) Name (optional): _______________________________________
b) Age:

40
40
40
42
46
48
62
55
72
74
Gender:

6Male

4 Female

Civil status:

Single

9 Married

1 Widow/Widower

Separated

Occupation:

Highest Educational Attainment:

3 Hs grad
 Vocational

6 College grad

Chief Complaint/ PT Diagnosis:

1 Cervical spondylosis

2 LBP

1 Cervical strain

2 Adcap

Number of treatment sessions/week:

1- 5 tx s/w

6- 3

2- 2

No. of treatment sessions attended:

6 mos

4 mos
I. Level of Satisfaction
Direction: Put a check mark on the space that best describe your level of satisfaction on
the following statements regarding services, facilities and treatment. Please be guided
with the scale below.

Scale Descriptive Equivalent

5 Very Much Satisfied

4 Much Satisfied

3 Moderate

2 Less Satisfied

1 Not Satisfied

A. Level of Satisfaction towards Hospital Management:

Hospital Management 5 4 3 2 1

1. Waiting time before treatment 5 4 1

2. Comfort in the waiting area 3 6 1

3. Timely response given by the physical 6 1 1 1

therapist

4. Interaction with the physical therapists 8 1 1

(approachable at all times)

5. Available space of the treatment area 5 1 2 2

6. Availability of services given in physical 4 4 1 1
therapy management

7. Eligibility and competitiveness of the physical 5 4 1

therapist during treatment

8. Ease of access going to the PT rehab 5 4 1

9. Appropriate amount of service charge to the 8 2

treatment given (Bill)

10. Overall Service of the Hospital 6 4

B. Level of satisfaction towards Physical Therapy Facilities and Equipment:

Facilities and Equipment 5 4 3 2 1

1. Availability of ramps and stairs for person 3 6 1

with disabilities

2. Availability of facilities in the hospital/clinic 4 6

(water in the comfort room, electricity, etc)

3. Cleanliness and orderliness of the Clinic 7 2 1

4. Accessibility of a reliable internet connection 1 3 1 5

(Wi-Fi)

5. Proper lighting of treatment area/clinic 5 4 1

6. Proper ventilation of the treatment area 4 5 1

7. Functionality and availability of machines/ 5 2 2 1

Equipment/ modalities

8. Availability and accessibility of treatment 4 4 1 1

areas/bed

9. Cleanliness and accessibility of comfort 4 5 1

rooms

10. Overall satisfaction towards Physical Therapy 5 4 1

Facilities and Equipment

C. Level of satisfaction towards Physical Therapy Program:

Physical Therapy Program 5 4 3 2 1

1. Strict implementation of 6 3 1
Appointment/Treatment time

2. Proper handling of patient/ clients before, 7 3

during, and after doing exercise

3. Approachability of the Physical therapists in 6 4

the hospital or clinic

4. Privacy during treatment (properly covered) 4 6

5. Physical Therapists care before, during and 5 5

after applying modalities

6. Demonstrates expertise in treatment 5 4 1

techniques (professionalism, ability, skill)

7. Clarity, simplicity, understandable 4 5 1

instructions are given during exercise

8. Comfort before, during and after treatment on 5 5

the treatment area

9. Given the appropriate knowledge about the 3 6 1

effects of the modality used

10. Overall care of the Physical Therapy 4 5 1

BGH