Patient Intake Form

PDF Format Download

MS Word Download

Listed below are additional forms that you can print and fill out to make your first visit and initial paperwork more efficient.

Consent to Treatment

Health History

HIPPA

Pool Rules

Patient Satisfaction Survey Form

In our effort to continuously provide the highest quality of care, your opinion helps our clinic with its ongoing commitment to improve our services.

Please take a few minutes to answer the following questions and return this brief survey to our front desk administrator.

If you wish to discuss any concerns or comments you may have please feel free to call us to speak with our clinic director.

If your browser doesnt allow online form submission you can also download this form here in both PDF and MS Word formats – click on the links below to download to your computer.

PDF Format Download

MS Word Download

Online Survey Form


Bowie
Laurel
Columbia
Severna Park
Catonsville
Therapy Received:


Physical Therapy
Aquatic Therapy
Both

Name(s) of your Primary Therapist(s)

Area(s) of Injury

Number of visits

What influenced you to choose Chesapeake Physical & Aquatic Therapy?


a. Location

b. Insurance

c. Newspaper/ Website

d. Convenient Hours of Clinic

e. Staff/ Reputation

f. Recommendation of Doctor

g. Recommendation of a friend

h. Other

If Other, please explain

The rating scale below is based on a 1-5 scale, 1 being the lowest score and 5 the highest or best score.

How available were your therapist’s hours?

Not at all
1
2
3
4
5 Very Available

How responsive was your therapist in addressing clinical issues?

Not at all
1
2
3
4
5 Very Responsive

Did your therapist provide information in a way that is clear, concise, understandable, and useful?

Not Clear
1
2
3
4
5 Very Clear

How helpful has therapy been in finding solutions to your problems?

Not Helpful
1
2
3
4
5 Very Helpful

Do you feel that the staff at Chesapeake Physical and Aquatic Therapy demonstrated a consistent level of knowledge necessary to fulfill your requests?

Not at all
1
2
3
4
5 Very Knowledgeable

How would you rate the competency of the clinical support staff?

Not at all
1
2
3
4
5 Very Competent

How would you rate the professionalism of the front desk?

Not Professional
1
2
3
4
5 Very Professional

Were you able to schedule your appointment(s) at a time(s) that was(were) convenient for you?

Not Convenient
1
2
3
4
5 Very Convenient

Did you feel that your time spent waiting to begin treatment was reasonable?

Not Reasonable
1
2
3
4
5 Very Reasonable

How would you rate the efficiency of the billing department?

Not at all
1
2
3
4
5 Very Efficient

Was the success of my therapy treatment program what I expected?
Less than Expected
1
2
3
4
5 More than I Expected

Would you recommend Chesapeake Physical & Aquatic Therapy to a friend?

Would not Recommend
1
2
3
4
5 Highly Recommend

What is your overall satisfaction level with Chesapeake Physical & Aquatic Therapy?
Not Satisfied
1
2
3
4
5 Very Satisfied

Please use the space below to comment on ways in which Chesapeake Physical & Aquatic Therapy can serve you better, or let us know about any concerns or compliments you may have.
We thank you for choosing Chesapeake Physical and Aquatic Therapy as your rehabilitation provider.