Aftercare Questionaire Dear Patient, We would appreciate a few minutes of your time to help us improve our patient care by answering a few questions about your recent treatment experience at Body Back-Up. Contact Details Your Name: Your Email: 1. How did you hear about Body Back-Up? Advert Advert Leaflet YP Website Online Directory Ins Co Cons Ref Pt Rec GP Ref GP Reception Other (If selected 'Other' please specify) 2. Have you received any of the following in relation to your current symptoms prior to attending Body Back-Up? No previous treatment X-Rays/MRI/CT Scan Physiotherapy Homeopathy Chiropractic treatment Acupuncture GP Consultation Blood Tests Orthopaedic Consultation Prescribed Medication 3. Tick the box that most reflects how you feel about the following: Were the Receptionists helpful in answering your questions? Yes No Don't Know N/A Was it easy to make an appointment? Yes No Don't Know N/A Was there an appointment available to suit you? Yes No Don't Know N/A Did you receive accurate directions to the Practice? Yes No Don't Know N/A 4. What were you looking for in attending Body Back-Up? (Tick box(es) that apply) Pain Relief Excersises Manipulation Postural check Massage Advice Maintenance treatment Reassurance An alternative to medication Information If other please (specify) 5. Do you feel you have been given sufficient information by your Osteopath? Yes No Unsure 6. Are you happy with your treatment progression so far? Yes No Unsure 7. Would you find a "6-month" check-up useful to keep you in good shape in future? Yes No 9. Were you aware that Osteopaths treat: Pregnant Women Children Sports Injuries Work related pain Work Injuries 10. Who would you feel happy to recommend your Body Back-Up Osteopath to:(Tick boxes(es) thats apply) Friends Colleagues Relations Would not reccomend 11. Did you find our website www.bodybackup.co.uk a useful source of information? Yes No 12. How do you rate your overall Body Back-Up experience? Excellent Good Fair Unsatisfactory Any further comments or suggestions The Date:12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 201220132014201520162017 Please Tick if you wish to not be contacted about future offers or promotions. To Submit Your form please enter the letters/numbers below and press submit, thank you.