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Evaluation Form
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13
Questions
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1
Where did you here about us?
*
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Internet
Friends or family
Social media
Flyer or business card
Other
Internet
Friends or family
Social media
Flyer or business card
Other
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2
Website
What did you think of our website
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Navigation
Ease of use
Responsiveness
Content
Navigation
Ease of use
Responsiveness
Content
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
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3
Pick one from the source you used
*
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Very poor
Not that bad
somewhat
good
Perfect
Online
24/7 booking line
Enquiries line
Online
24/7 booking line
Enquiries line
Very poor
Not that bad
somewhat
good
Perfect
Very poor
Not that bad
somewhat
good
Perfect
Very poor
Not that bad
somewhat
good
Perfect
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4
Select relevant box for each one
*
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Very poor
Not that bad
Somewhat
Good
Perfect
Professionalism
Knowledge
Compassion
Communication
Professionalism
Knowledge
Compassion
Communication
Very poor
Not that bad
Somewhat
Good
Perfect
Very poor
Not that bad
Somewhat
Good
Perfect
Very poor
Not that bad
Somewhat
Good
Perfect
Very poor
Not that bad
Somewhat
Good
Perfect
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5
Select relevant box
*
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Very poor
Not that bad
Somewhat
Good
Perfect
Facilities
Facilities
Very poor
Not that bad
Somewhat
Good
Perfect
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6
Overall, were you satisfied with the facilities we use?
*
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Yes
No
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7
Please add any additional comments here?
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8
Would you recommend Empire Physiotherapy to a friend?
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Yes, definitely
Maybe, if it was cheaper
No, never
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9
Is there any aspect of our service that you would like us to change?
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10
Any final comments?
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11
Your Name
First Name
Last Name
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12
E-mail
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13
Phone Number
Area Code
Phone Number
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