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Overview of Services
Non-Surgical Back Treatment
Drug & Alcohol Testing
Independent Medical Exam
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Physical Exams
Physical Therapy
Specialty Services
On Site Services
Patient Survey
Patient Information
Patient Age
18-25
26-35
36-45
46-55
56 & Older
Patient Gender
Male
Female
Position with Company
Please rate Comprehensive Care on the following
5 = Excellent 1 = Poor
Attended to in a timely manner:
5
4
3
2
1
Courtesy / Attitude of Employees:
5
4
3
2
1
Patient Care:
5
4
3
2
1
Clinic Appearance / Cleanliness:
5
4
3
2
1
Relationship with Medical Staff:
5
4
3
2
1
Relationship with Doctors / Therapists:
5
4
3
2
1
Rate Comp. Care vs. other health care experiences:
5
4
3
2
1
Overall Experience:
5
4
3
2
1
General Health Care Questions:
5 = High Priority 1 = No Concern
Importance of a solid company Health Plan:
5
4
3
2
1
Rating of your companies Health Plan:
5
4
3
2
1
Comfort with the Internet for health questions:
5
4
3
2
1
Would you be interested in any of the following programs for your employees:
(Check all that apply)
Weight Loss
Work Hardening
Stop Smoking
Wellness
Healthy Eating
Physical Therapy
Ergonomic Evaluation
Sport Performance
Newsletter / E-Letter
Stress Management
Other
If other is selected, please specify:
General Comments:
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