This feedback template includes 11 fields. Gather patient feedback on treatment effectiveness, therapist skill, scheduling, and clinic environment. Free to customize and use on ZenBuild.
Patient Name (text, optional)
Email Address (email, optional)
Treatment Type (dropdown selection, required) — options: Post-Surgery Rehab, Sports Injury, Chronic Pain, Balance & Fall Prevention, Other
Effectiveness of Treatment (rating, required)
Therapist Knowledge & Skill (rating, required)
Therapist Bedside Manner (rating, required)
Ease of Scheduling (rating, required)
Clinic Cleanliness (rating, required)
Did Your Condition Improve? (multiple choice, required) — options: Significantly, Somewhat, Minimally, No Change
Would You Return or Recommend? (multiple choice, required) — options: Yes, Maybe, No
