Q01
メッセージ
すべてのテンプレートHealthcare & Clinical
Physical Therapy Progress & Experience Evaluation
Tracks a patient's pain, functional ability, home exercise adherence, and satisfaction with their physical therapy plan of care, with an AI follow-up that digs into what's really getting in the way of progress. Built for outpatient PT clinics running periodic check-ins or discharge reviews.
設問の例
テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。
全13問・約7分
Q02
選択式必須
What body area or condition are you currently receiving physical therapy for?
- Low back
- Neck or upper back
- Shoulder
- Knee
- Hip
- Ankle or foot
- Wrist or hand
- Post-surgical recovery
- Balance or fall prevention
Q03
オピニオンスケール必須
Right now, how would you rate your pain?
スケール: 0 – 10
最小:No pain最大:Worst pain imaginable
Q04
マトリクス必須
In the last 7 days, how much difficulty have you had with each of the following?
6行 × 5列
- Walking short distances
- Climbing stairs
- Getting up from a chair or bed
- Reaching overhead
- Lifting or carrying objects
- ほか1件
列: No difficulty · Slight difficulty · Moderate difficulty · Severe difficulty · Unable to do
Q05
オピニオンスケール必須
How much progress do you feel you've made toward the personal goals you set with your therapist?
スケール: 1 – 7
最小:No progress at all最大:Fully achieved my goals
Q06
選択式必須
In the past 7 days, on how many days did you complete your prescribed home exercises?
- 0 days
- 1-2 days
- 3-4 days
- 5-6 days
- 7 days (every day)
Q07
選択式
What has made it hardest to keep up with your home exercises? Select all that apply.
- Exercises caused too much pain
- Not enough time
- Forgot to do them
- Instructions weren't clear
- Not sure they're helping
- Lack of motivation
Q08
評価スケール必須
How clearly has your therapist explained your condition and how to do your exercises correctly?
範囲: 1 – 5
最小:Not clear at all最大:Extremely clear
Q09
AIインタビュー
Explore the gap between the patient's reported pain/functional difficulty and their sense of progress toward goals. If they reported low home-exercise adherence or specific barriers, probe concretely which exercises they skip, why, and whether pain during exercise is a factor versus time or motivation. If they report high adherence but low progress, probe whether the exercises feel matched to their goals or need to be adjusted. Anchor on specific recent sessions rather than general impressions.
Q10
オピニオンスケール必須
How likely are you to recommend this physical therapy clinic to a friend or family member?
スケール: 0 – 10
最小:Not at all likely最大:Extremely likely
Q11
選択式
What is your age range?
- Under 18
- 18-29
- 30-44
- 45-59
- 60-74
- 75 or older
- Prefer not to say
Q12
選択式
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q13
メッセージ
Thank you for sharing this update. Your responses go directly to your care team to help fine-tune your treatment plan and are also used, in aggregate, to improve how we support patients like you.
含まれる機能
AIによる深掘り
自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。
注意確認設問
急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。
AIが作成する設問文
文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。
自動レポート
回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。
他ツールとの比較
ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。
このテンプレートを選ぶ理由
- Goes beyond static pain/function ratings with an AI follow-up interview specifically designed to dig into what's really blocking progress, not just capture a score
- Combines a pain rating, a matrix of functional difficulty items, home exercise adherence tracking, and reasons for non-adherence in one flow rather than a single generic evaluation form
- Includes clinician-relevant clarity questions (how well the therapist explained the condition and exercises) alongside outcome and satisfaction/recommendation measures
- Opens and closes with clear chat messages framing the check-in and confirming responses go to the patient's care team, which builds trust and context missing from plain form fields
Jotform
Physical Therapy Evaluation Form TemplateA standard fillable form template for capturing physical therapy evaluation details, built on Jotform's drag-and-drop form builder. It's fielding-ready out of the box and easy to customize with their editor, but it's a static field-based form rather than a conversational or adaptive survey. No mechanism to probe deeper into a patient's specific barriers to progress.
優れている点
- Fielding-ready template usable immediately
- Easy drag-and-drop customization within Jotform's ecosystem
- Likely integrates with Jotform's broader form/e-signature/workflow tools
物足りない点
- Static form fields only — no adaptive AI follow-up to explore why a patient's pain or function isn't improving
- No automated quality scoring of individual responses
- No voice AI interview option for patients who prefer speaking over typing
SurveySparrow
Physical Therapy Evaluation Form TemplateA conversational-style survey template aimed at healthcare use cases, which fits the same audience as this template. It offers a more engaging one-question-at-a-time format than a plain form, but its 'conversational' feel is templated and scripted rather than a true adaptive interview that reacts to what the patient says.
優れている点
- Conversational, one-at-a-time UI likely improves completion rates versus a dense form
- Positioned specifically for healthcare templates, suggesting relevant field types
- Fielding-ready template for quick deployment
物足りない点
- No genuine adaptive AI questioning — flow is pre-scripted rather than dynamically probing individual answers
- No per-response automated quality scoring reported
- No published methodology for how follow-up questions (if any) are generated
Typeform
Physical Therapy Evaluation Form TemplateTypeform's well-known conversational form format applied to a physical therapy evaluation, offering a polished, mobile-friendly respondent experience. It's a strong fielding-ready template, but like other form builders it lacks true adaptive branching driven by an AI reading and reacting to open-ended answers in real time.
優れている点
- Polished, mobile-friendly conversational interface
- Fielding-ready template within a widely used survey platform
- Logic-based branching for basic conditional flows
物足りない点
- No AI-driven follow-up interview that adapts based on the substance of a patient's answers
- No automated per-response quality scoring
- No voice AI interview or guided screen-share task option
よくあるご質問
「Physical Therapy Progress & Experience Evaluation」テンプレートにはどのような設問が含まれていますか？
すぐに使える設問が13問含まれており、最初の設問は次のとおりです：「Thanks for taking a few minutes to check in on your physical therapy. Your answers help your care team adjust your plan…」・「What body area or condition are you currently receiving physical therapy for?」・「Right now, how would you rate your pain?」。すべての設問は上でプレビューでき、自由に編集できます。
このアンケートの回答にはどのくらい時間がかかりますか？
回答者は通常、13問を約7分で回答し終えます。
テンプレートは編集できますか？
はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。
このテンプレートは無料で使えますか？
はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。
公開の準備はできましたか？
このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。
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