Patient: [FPO]
Survey Date: [FPO]
Very good
Good
Acceptable
Poor
Very poor
Extremely satisfied
Very satisfied
Satisfied
Slightly unsatisfied
Unsatisfied
Completely clear
Clear
Somewhat clear
Minimal clearance
No clearance
Gratitude
Confident
Hopeful
Relieved
Neutral/Expectations met
Overwhelmed
Doubtful
Discouraged
None of the above
Strongly agree
Agree
Slightly agree
Neutral
Slightly disagree
Disagree
Strongly disagree
Strongly agree
Agree
Slightly agree
Neutral
Slightly disagree
Disagree
Strongly disagree
This is my first treatment experience
A - Excellent
B - Very good
C - Average/good
D - Below average
F - Fail/poor
Strongly agree
Agree
Slightly agree
Neutral
Slightly disagree
Disagree
Strongly disagree
This is my first treatment experience
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