Treatment questionaire

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Treatment Questionnaire

Please take a few minutes to print this document then fill out the questions. This is

optional and all information is confidential.

Please send your completed response to:

Orthopaedic Associates 75 Pringle Way #912 Reno, NV 89502

You may also bring this form to your next visit and drop off at check-in

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 did you spend 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. Who was your treating doctor- Webster Preston Davis (circle one)
2. Did you eventually have surgery- yes no (circle one) NO-SKIP TO 12
3. How long after your first office visit did you have surgery- <1 wk 1-2wks
2-6wks <3mo 3-6mo >6mo (circle one)
4. Did you have Physical Therapy BEFORE surgery- yes no (circle one)
5. 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
6. 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)
7. Were you satisfied with your results of treatment- yes no (circle one)
8. Would you have surgery again for the same problem- yes no (circle one)
9. What surgery did you have: Fracture (broken bone) surgery
Arthroscopic surgery Spine (fusion or disc) surgery
Joint replacement surgery Hand surgery Foot surgery
(circle one or write in the name of your procedure here)_________________________________________________________________
10. Do you feel an adequate period of non-surgical treatment was tried prior
to surgery- yes no (circle one)
11. Please rate your post-operative Physical Therapy care:
1 least to 5 most helpful- 1 2 3 4 5 (circle one)
12. Please give an overall rating for your care at Orthopaedic Associates: 1 least
to 5 best- 1 2 3 4 5 (circle one)

Name (optional)_____________________________________________________________________

Dates of treatment (mo/yr)___________________________________

Comments/suggestions__________________________________________________________________________

__________________________________________________________________________________