Q01
Message
All templatesHealthcare & Clinical
Physical Therapy Patient Experience Evaluation
Measures how patients experience physical therapy care — clarity of communication, pain management during exercises, and real functional progress — built for clinics, rehab practices, and outpatient PT groups. The AI follow-up interview digs past satisfaction scores to reconstruct what actually happened in sessions and why recovery felt fast, slow, or stalled.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple ChoiceRequired
How many physical therapy sessions have you completed as part of your current treatment plan?
- 1-3 sessions
- 4-6 sessions
- 7-10 sessions
- More than 10 sessions
Q03
MatrixRequired
Thinking about your sessions overall, how would you rate your therapist on each of the following?
5 rows × 5 columns
- Communicated clearly about your treatment plan
- Listened to your concerns and pain levels
- Explained exercises so you could do them correctly on your own
- Was punctual and used your session time well
- Adjusted treatment when you reported pain or difficulty
Columns: Poor · Fair · Good · Very Good · Excellent
Q04
Opinion ScaleRequired
How clearly did your therapist explain the goals of your treatment plan?
Scale: 1 – 5
Min:Not at all clearlyMax:Extremely clearly
Q05
Rating ScaleRequired
Compared to when you started treatment, how much has your physical function or mobility improved?
Range: 1 – 5
Min:No improvementMax:Fully recovered function
Q06
Multiple Choice
During exercises that caused some discomfort, how well did your therapist manage your pain level?
- Always managed appropriately
- Usually managed appropriately
- Sometimes pushed too hard
- Often pushed too hard
- I did not experience discomfort during exercises
Q07
Opinion ScaleRequired
How likely are you to recommend this physical therapist to a friend or family member dealing with a similar condition?
Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q08
AI Interview
Probe the story behind the respondent's recommendation score and their reported functional improvement. Ask them to describe one specific session that stands out — good or bad — and what the therapist did or didn't do. If they gave a low recommendation score or reported little improvement, dig into what specifically stalled progress (pain management, unclear instructions, feeling rushed) and what would have changed the outcome. If they gave a high score, find out which specific behavior from the therapist drove that trust.
Q09
Multiple Choice
Which parts of your care, if any, would you like to see improved?
- Scheduling flexibility
- Wait times before sessions
- Clarity of home exercise instructions
- Amount of one-on-one time with therapist
- Communication between visits
- Nothing - I'm satisfied with my care
Q10
Multiple Choice
What is your age range?
- Under 18
- 18-29
- 30-44
- 45-59
- 60-74
- 75 or older
- Prefer not to say
Q11
Multiple Choice
What is your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q12
Dropdown
What was the primary reason you sought physical therapy?
- Post-surgical rehabilitation
- Sports or musculoskeletal injury
- Chronic pain management
- Neurological condition
- Fall prevention or balance issues
- Other
- Prefer not to say
Q13
Message
That's everything — thank you! Your responses will be shared with the clinic's care quality team to recognize what's working and improve what isn't.
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Goes beyond a satisfaction score with an AI follow-up interview that probes the story behind a patient's recommendation rating and why recovery felt fast, slow, or stalled
- Combines structured measurement (matrix rating of therapist behaviors, opinion scales on clarity of goals and likelihood to recommend, a functional-progress rating) with open-ended reconstruction of what actually happened in sessions
- Directly asks how well pain was managed during uncomfortable exercises, not just overall satisfaction
- Closes with a transparent note that responses are shared with the clinic's care team, plus demographic and reason-for-care questions for segmentation
Jotform
Physical Therapy Evaluation Form TemplateA ready-to-field static form for collecting patient feedback on physical therapy care, built on Jotform's drag-and-drop form builder. It covers standard evaluation fields but relies on fixed questions rather than any adaptive follow-up. Good for quick deployment and easy embedding into clinic intake workflows.
What it does well
- Fast to deploy and customize via Jotform's builder
- Widely used, familiar form format for clinics
- Easy integration with Jotform's broader forms/e-signature ecosystem
Where it falls short
- Static question set with no adaptive AI follow-up to probe why recovery felt fast, slow, or stalled
- No automated per-response quality scoring
- No published methodology for how questions map to outcomes
SurveySparrow
Physical Therapy Evaluation Form TemplateA conversational-style survey template for physical therapy evaluation, fielding-ready within SurveySparrow's chat-like survey format. It's designed for a friendlier respondent experience but still uses pre-set questions rather than dynamic AI-driven probing. Suited for clinics wanting a simple, mobile-friendly feedback loop.
What it does well
- Conversational UI that may improve completion rates
- Fielding-ready template for healthcare feedback
- Mobile-friendly survey delivery
Where it falls short
- No adaptive AI follow-up interview to dig into the story behind scores
- No optional voice AI interview option
- No automated report generation tied to per-response quality scoring
Typeform
Physical Therapist Evaluation Form TemplateA polished, fielding-ready one-question-at-a-time form for evaluating physical therapists, built on Typeform's well-known conversational form format. It emphasizes visual design and respondent experience but the question flow is fixed rather than adaptive to individual answers. Works well for basic satisfaction capture rather than deeper diagnostic follow-up.
What it does well
- Clean, engaging one-question-at-a-time interface
- Strong design and branding customization
- Established, fielding-ready template
Where it falls short
- No AI-driven follow-up questioning to reconstruct what happened in sessions
- No guided task or screen-share capability
- No transparent, published prompt methodology for how insights are derived
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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