Charles Street Surgery
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Physiotherapy Questionnaire

Once you have completed the form please click 'Submit'.
"*" denotes a required field.

 
Personal Details
 
     
  Surname *
  First Name *
 
Questions
 
Private Referrals Only
 

1. Was your referral under the NHS? (rather than private)     

Yes No
   

If NHS answer questions 2 – 13 only
If private answer questions 10  – 16 only
   
 

2. Would you have preferred a private physio if one had been available on the NHS?     
Yes No
Please give your main reasons for this:
   
3. Are you likely to elect for NHS treatment again in the future?   
Yes No
Please give your main reasons for this:
 
4. Did your doctor give you an estimated waiting time?
Yes No
                       
5. Were you happy with the waiting time advised?
Yes No
 
6. How quickly did you hear about your appointment?
   
   
7. Was your first appointment date within the waiting time?
Yes No
If "No", approximately how long did you have to wait?
 
 
8. Were you given a choice of treatment locations?
Yes No
Which location was provided / agreed?
 
9. Was the location provided convenient for you?
Yes No
                     
 
If "No", where would you have preferred to go?
 
         
 
10. Did you attend your first appointment?
Yes No
If "No", what was your main reason for this?
 
11. At your appointment were you seen promptly?
Yes No
If "No", how long did you wait?
Were you happy with this ?
 
12. Did you complete your course of treatment?
Yes No
If "Yes", how many sessions did you attend?
Did you always see the same physio?
Did you feel that the physio understood your needs?
Did the sessions help resolve your problem?
If the problem was not resolved, how has this been followed up ?
                 
If "No", what was the main reason for this?
 
13. Do you have any other comments or suggestions relating to the physio service received?
   
14. What were your main reasons for deciding on a private rather than an NHS referral?
   
15. What influenced your choice of individual physiotherapist / practice? (select all that apply)
Recommended by GP
Recommended by other Person
Personal Knowledge
Specialism
Location
Price
Waiting Times
                   
16. Are you likely to elect for private treatment again in the future?
Yes No
What are your main reasons for this?
 
 
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