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Treatment Questionnaire                    ( Comments/suggestions- please write on back)

Print this document then fill out the questions. This is optional and all information is confidential.

Bring this form to your next visit and drop off at check-in with the front office receptionist.

Email or FAX your completed response to: Orthopaedic Associates Fax 786-9257

A. For your last office visit:

• 1. How long after you scheduled was your appointment- 

•     same day  next day  3-5days  1-2wks  >2wks(circle one)                                                                     

• 2. Please rate the office staff:  Reception, Medical Assistants, X-ray Technicians:
•     1 least to 5 most helpful- 1  2  3  4  5  (circle one)
• 4. How long after your appointment time were you in the waiting room-                                             
•     <5min <10min 15-30min  45-60min   >1hr (circle one)
• 5. Please rate the professionalism of your doctor: 1 least to 5 most-
•     1  2  3  4  5 (circle one)
• 6. How much total time from check-in to check-out were you in the office-                                               
•     <30min 30-45min  45-60min  1-11/2hrs  >2hrs  (circle one)
• 7. Did you have to wait for a referral authorization before being seen- 
•     yes  no (circle one)
• 8. Were you satisfied with your appointment time-  yes  no  (circle one)
• 9. Were you satisfied with your office visit-  yes  no  (circle one)
• 10. Please rate the quality of your follow-up calls to Medical Assistants, 
•       Surgery scheduling, etc: 1 least to 5 most helpful- 1  2  3  4  5  (circle one)

B. For your Treatment

• 1. Did you have surgery-  yes  no  (circle one) NO-SKIP TO 7
• 2. How long after your first office visit did you have surgery-  
•     <1 wk  1-2wks   2-6wks  <3mo  3-6mo  >6mo (circle one)
• 3. Did you have surgery to reduce pain-  yes  no  (circle one)

•             a. Please rate your pain before treatment: 0 none to 10 most

•                 0  1  2  3  4  5  6  7  8  9  10                                                                             

•             b. Please rate your pain at your final office visit: 0 none to 10
•                 0  1  2  3  4  5  6  7  8  9                                                                                                                                          
• 4. Did you have surgery to improve function i.e. ability to lift, ability to walk, 
•     ability to work or play sports-               yes  no  (circle one)
•             a. Please rate your function before treatment: 0 worst to 10 best-
•                 0  1  2  3  4  5  6  7  8  9  10 (circle one)
•             b. Please rate your function at your final office visit: 0 to 10-                           
•                 0  1  2  3  4  5  6  7  8  9  10  (circle one)
• 5. Were you satisfied with your results of treatment-  yes  no  (circle one)
• 6. Would you have surgery again for the same problem- yes  no  (circle one)

• 7. Please rate your Physical Therapy care: 

•     1 least to 5 most helpful-  1  2  3  4  5 (circle one)

• 8. Please give an overall rating for your care at Orthopaedic Associates: 
•     1 least to 5 best-  1  2  3  4  5 (circle one)