ࡱ>  bjbj jjl0008hdOLttty{{{= 3 K$M %OpKA@Kmt Lmmmtymymm565t \y]a,0-55DL0OL5OO5m  Dance Clinic Patient Satisfaction Survey Top of Form DATE SEEN:  HTMLCONTROL Forms.HTML:Text.1 \s  How did you hear about the Harkness Center?  HTMLCONTROL Forms.HTML:Text.1 \s Please check: Which doctor did you see in clinic today?  HTMLCONTROL Forms.HTML:Option.1 \s Dr. Rose  HTMLCONTROL Forms.HTML:Option.1 \s Dr. Weiss Which physical therapist did you see?  HTMLCONTROL Forms.HTML:Option.1 \s Alison  HTMLCONTROL Forms.HTML:Option.1 \s Bliss  HTMLCONTROL Forms.HTML:Option.1 \s Emily  HTMLCONTROL Forms.HTML:Option.1 \s Faye  HTMLCONTROL Forms.HTML:Option.1 \s Megan  CONTROL Forms.OptionButton.1 \s  Vanessa  CONTROL Forms.OptionButton.1 \s   CONTROL Forms.TextBox.1 \s  Please rate the following regarding your experiences at the Harkness Center on a scale from 1 to 4. 1 = Poor 2 = Fair 3 = Good 4 = Excellent  Administrative Support Rating Phone Manner  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s  3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Communication skills  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s 3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Payment and billing policies  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s 3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Hours of availability  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s  3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Punctuality  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s 3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Physician Rating Physician's concern regarding your questions/special needs  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s 3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Time physician spent with you  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s  3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Physician's knowledge of dance and dance injuries  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s  3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Physician's explanation to you about your diagnosis and plan of care  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s  3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Physician's communication skill with you and your family  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s 3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Physical Therapist Rating Physical therapist's knowledge of dance and dance injuries  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s 3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Physical therapist's concern regarding your questions/special needs  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s 3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Physical therapist's explanations to you regarding your treatment plan and goals  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s 3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Scheduling of appointments for physical therapy  HTMLCONTROL Forms.HTML:Option.1 \s 1  HTMLCONTROL Forms.HTML:Option.1 \s 2  HTMLCONTROL Forms.HTML:Option.1 \s 3  HTMLCONTROL Forms.HTML:Option.1 \s 4 Please tell us: Were you advised about how, if and when to return to your dance activities?  HTMLCONTROL Forms.HTML:Option.1 \s Y  HTMLCONTROL Forms.HTML:Option.1 \s N Were you given a home exercise program and/or other plan of care to follow?  HTMLCONTROL Forms.HTML:Option.1 \s Y  HTMLCONTROL Forms.HTML:Option.1 \s N Did you receive satisfactory explanations about your examination, diagnostic tests and condition?  HTMLCONTROL Forms.HTML:Option.1 \s Y  HTMLCONTROL Forms.HTML:Option.1 \s N What do you consider to be the strongest aspect of our Center?  HTMLCONTROL Forms.HTML:TextArea.1 \s  What do you consider to be the weakest aspect of our Center and what improvements would you like to suggest?  HTMLCONTROL Forms.HTML:TextArea.1 \s  Please add any additional comments, suggestions or opinions that you have.  HTMLCONTROL Forms.HTML:TextArea.1 \s  Thank you for filling out this questionnaire, it will be used for improving patient care.  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VALUE="4">_1178539179U\g+x]a021x]aCompObjKqObjInfoMOCXDATANrOCXNAMEP_1178539180U\g021x]aP8x]aCompObjQqObjInfoSHTMLOption43 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="comm" VALUE="1">HTMLOption44 U\gForms.HTML:Option.1EmbeddedOCXDATATdOCXNAMEV_1178539182U\gP8x]apt@x]aCompObjWq ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="comm" VALUE="2">HTMLOption45 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2ObjInfoYOCXDATAZdOCXNAME\_1178539184U\gpt@x]a0Ix]aCompObj]qObjInfo_OCXDATA`dOCXNAMEbU\g<INPUT TYPE="RADIO" NAME="comm" VALUE="3">HTMLOption46 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="comm" VALUE="4">_1178539186 U\g0Ix]aJTx]aCompObjcqObjInfo  eOCXDATA fdOCXNAMEh_1178539187U\gJTx]a[x]aCompObjiqObjInfokHTMLOption47 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="danceknow" VALUE="1">HTMLOption48 U\gForms.HTML:Option.1EmbeddedOCXDATAlnOCXNAMEn_1178539189 U\g[x]aЌcx]aCompObjoq ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="danceknow" VALUE="2">HTMLOption49 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2d     WV !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUXYZ\[]_^`abeck{fghijlrmnopqtszuvwxy|~}ObjInfoqOCXDATArnOCXNAMEt_1178539191U\gЌcx]a@bnx]aCompObjuqObjInfowOCXDATAxnOCXNAMEzU\g<INPUT TYPE="RADIO" NAME="danceknow" VALUE="3">HTMLOption50 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="danceknow" VALUE="4">_1178539193DU\g@bnx]a`vx]aCompObj{qObjInfo}OCXDATA ~nOCXNAME_1178539195#U\g`vx]a}x]aCompObjqObjInfo"$HTMLOption51 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="ptconcern" VALUE="1">HTMLOption52 U\gForms.HTML:Option.1EmbeddedOCXDATA%nOCXNAME_1178539196!+(U\g}x]ax]aCompObjq ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="ptconcern" VALUE="2">HTMLOption53 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2ObjInfo')OCXDATA*nOCXNAME_1178539198-U\gx]a `x]aCompObjqObjInfo,.OCXDATA/nOCXNAMEU\g<INPUT TYPE="RADIO" NAME="ptconcern" VALUE="3">HTMLOption54 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="ptconcern" VALUE="4">_1178539200&:2U\g `x]a@x]aCompObjqObjInfo13OCXDATA4nOCXNAME_11785392027U\g@x]ax]aCompObjqObjInfo68HTMLOption55 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="ptexp" VALUE="1">HTMLOption56 U\gForms.HTML:Option.1EmbeddedOCXDATA9fOCXNAME_11785392035?<U\gx]a ʣx]aCompObjq ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="ptexp" VALUE="2">HTMLOption57 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2ObjInfo;=OCXDATA>fOCXNAME_1178539205AU\g ʣx]ax]aCompObjqObjInfo@BOCXDATACfOCXNAMEU\g<INPUT TYPE="RADIO" NAME="ptexp" VALUE="3">HTMLOption58 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="ptexp" VALUE="4">_11785392070XFU\g@kx]a` x]aCompObjqObjInfoEGOCXDATAHfOCXNAME_1178539209KU\g` x]ax]aCompObjqObjInfoJLHTMLOption59 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="sched" VALUE="1">HTMLOption60 U\gForms.HTML:Option.1EmbeddedOCXDATAMfOCXNAME_1178539211ISPU\gx]aNx]aCompObjq ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="sched" VALUE="2">HTMLOption61 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2ObjInfoOQOCXDATARfOCXNAME_1178539212UU\gNx]a`vx]aCompObjqObjInfoTVOCXDATAWfOCXNAMEU\g<INPUT TYPE="RADIO" NAME="sched" VALUE="3">HTMLOption62 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="sched" VALUE="4">_1178539214NlZU\g`vx]aKx]aCompObjqObjInfoY[OCXDATA\fq ĻĖFqw5i  y*D(T83Z'?\Z77㖳DDcJYWz,ckz &p ,K|+=ՅVklp929_Ws8p:k (sBX{q#Jh0؜?{@Z{+5/DdJ c C A ? 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"B2N8Zo;za*E~#`!"8Zo;za|xŒ 0ƿKbŵ ⠋NT"E|,'qr}q ĻĖFqw5i  y*D(T83Z'?\Z77㖳DDcJOCXNAME_1178539216_U\gKx]asx]aCompObjqObjInfo^`HTMLOption63 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="return" VALUE="yes">HTMLOption64 U\gForms.HTML:Option.1EmbeddedOCXDATAalOCXNAME_1178539218]gdU\gsx]a!x]aCompObjq ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="return" VALUE="no">HTMLOption65 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2ObjInfoceOCXDATAfjOCXNAME_1178539220iU\g!x]aIx]aCompObjqObjInfohjOCXDATAklOCXNAMEU\g<INPUT TYPE="RADIO" NAME="exprog" VALUE="yes">HTMLOption66 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="exprog" VALUE="no">_1178539221bvnU\gIx]apqx]aCompObjqObjInfomoOCXDATApjOCXNAME_1178539223sU\gpqx]ay]aCompObjqObjInfortHTMLOption67 U\gForms.HTML:Option.1Embedded ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="satisexpl" VALUE="yes">HTMLOption68 U\gForms.HTML:Option.1EmbeddedOCXDATAurOCXNAME_1178539225qxU\gy]ay]aCompObjq ControlForms.HTML:Option.19q2U\g<INPUT TYPE="RADIO" NAME="satisexpl" VALUE="no">HTMLOption69LE Z-  P- !P !O- !O !ObjInfowyOCXDATAzpOCXNAME_1178539227}$U\gy]ay]aPRINT CompObj|uObjInfoOCXDATA~r      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHJMPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxy{~- !N !N@@@- !M !  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L- ! ? ! ?- ! @- !G- !F- !E- !D- !F- !E- !D- !C 2 >N' $U\gForms.HTML:TextArea.1Embedded ControlForms.HTML:TextArea.19q2$U\g<TEXTAREA COLS="143" NAME="weak"></TEXTAREA>HTMLTextArea2LE Z-  PObjInfoKOCXDATALhOCXNAMEN_1178539230$U\g"y]aо+y]aPRINTO CompObjzuObjInfo|OCXDATA}p- !P !O- !O !- !N !N@@@- !M !  PI 2 >.- ! !!- ! !- ! ! - !  ! - !  -B( UUUU- ! - ! "- ! !- ! !- ! ! - !  ! - ! - ! - ! - ! - ! - !- ! - ! - ! - !. !=- !. !.- !/ ! <- ! / ! /- ! 0- !8- !7- !6- !5- !7- !6- !5- !4- !>! !M- !> !>- !? ! L- ! ? ! ?- ! @ - !> - !>"- !> !M- !> !>- !? ! L- ! ? ! ?- ! @- !G - !F - !E - !D - !F- !E - !D - !C - !> !M- !> !>- !? ! L- ! ? ! ?- ! @- !G- !F- !E- !D- !F- !E- !D- !C 2 >N' $U\gForms.HTML:TextArea.1Embedded ControlForms.HTML:TextArea.19q2$U\g<TEXTAREA COLS="143" NAME="comments"></TEXTAREA>HTMLTextArea3OCXNAME_1178539232U\gо+y]aP1y]aPRINTTCompObj} &  1@@@- !0 !0- ! !/- !/ !.- ! !-- !-- !+  1I.@Arialw@ }ww0-  2 S - !-2 ubmit' U\gForms.HTML:Submitbutton.1Embedded ControlForms.HTML:Submitbutton.19q2U\g<INPUT TYPE="SUBMIT">HTMLSubmit1Oh+'0ObjInfoOCXDATA:OCXNAME1TableOYWz,ckz &p ,K|+=ՅVklp929_Ws8p:k (sBX{q#Jh0؜?{@Z{+5DdhJ + C A? "C2N8Zo;za*E#`!"8Zo;za|xŒ 0ƿKbŵ ⠋NT"E|,'qr}q ĻĖFqw5i  y*D(T83Z'?\Z77㖳DDcJYWz,ckz &p ,K|+=ՅVklp929_Ws8p:k (sBX{q#Jh0؜?{@Z{+5DdhJ , C A? "D2N8Zo;za*E#`!"8Zo;za|xŒ 0ƿKbŵ ⠋NT"E|,'qr}q ĻĖFqw5i  y*D(T83Z'?\Z77㖳DDcJYWz,ckz &p ,K|+=ՅVklp929_Ws8p:k (sBX{q#Jh0؜?{@Z{+5DdhJ - C A? "E2N8Zo;za*E#`!"8Zo;za|xŒ 0ƿKbŵ ⠋NT"E|,'qr}q ĻĖFqw5i  y*D(T83Z'?\Z77㖳DDcJYWz,ckz &p ,K|+=ՅVklp929_Ws8p:k (sBX{q#Jh0؜?{@Z{+5DdhJ . C A? "F2N8Zo;za*E#`!"8Zo;za|xŒ 0ƿKbŵ ⠋NT"E|,'qr}q ĻĖFqw5i  y*D(T83Z'?\Z77㖳DDcJYWz,ckz &p ,K|+=ՅVklp929_Ws8p:k (sBX{q#Jh0؜?{@Z{+5DdhJ / C A? "G2N8Zo;za*El#`!"8Zo;za|xŒ 0ƿKbŵ ⠋NT"E|,'qr}q ĻĖFqw5i  y*D(T83Z'?\Z77㖳DDcJYWz,ckz &p ,K|+=ՅVklp929_Ws8p:k (sBX{q#Jh0؜?{@Z{+5DdhJ 0 C A? "H2N8Zo;za*EX#`!"8Zo;za|xŒ 0ƿKbŵ ⠋NT"E|,'qr}q ĻĖFqw5i  y*D(T83Z'?\Z77㖳DDcJYWz,ckz &p ,K|+=ՅVklp929_Ws8p:k (sBX{q#Jh0؜?{@Z{+5DdhJ 1 C A? "I2N8Zo;za*ED#`!"8Zo;za|xŒ 0ƿKbŵ ⠋NT"E|,'qr}q ĻĖFqw5i  y*D(T83Z'?\Z77㖳DDcJYWz,ckz &p ,K|+=ՅVklp929_Ws8p:k (sBX{q#Jh0؜?{@Z{+5Dd+J  C A? "J2Fi,Yhm0#`!Fi,Yhm PFl xڍnA=x8l%\re"q#Av@j۝.)[I36H>5\5pODZm>?ѺOu,~ÑCn_:"o~pwyh4y2}9B'ɅHl12aJcdGt@Zz "V]7acv0mWsЃ~{Q]“K-Aꋱc.RlO>'jh{S2k9q5f\G2?VxCG=VWwLߛעR^2EߓJ-1ě8؛ӌ8-:*b*2OM2]Ek)2OL2=Eg4<6dvL2&]̎If$ec*zLC)cwI`(ycdPd؛dPnWtВo{:Y.(tKt\K^T3]Qz½V<=ldP^bekERw{V|譙P[+8c9WɜE愫dlU2cȌJ-2l [d"-2ȜE&۔̻ JVX%+ئTDd+J  C A? "K2Fi,Yhm#`!Fi,Yhm PFl xڍnA=x8l%\re"q#Av@j۝.)[I36H>5\5pODZm>?ѺOu,~ÑCn_:"o~pwyh4y2}9B'ɅHl12aJcdGt@Zz "V]7acv0mWsЃ~{Q]“K-Aꋱc.RlO>'jh{S2k9q5f\G2?VxCG=VWwLߛעR^2EߓJ-1ě8؛ӌ8-:*b*2OM2]Ek)2OL2=Eg4<6dvL2&]̎If$ec*zLC)cwI`(ycdPd؛dPnWtВo{:Y.(tKt\K^T3]Qz½V<=ldP^bekERw{V|譙P[+8c9WɜE愫dlU2cȌJ-2l [d"-2ȜE&۔̻ JVX%+ئTDd+J  C A? "L2Fi,Yhm2#`!Fi,Yhm PFl xڍnA=x8l%\re"q#Av@j۝.)[I36H>5\5pODZm>?ѺOu,~ÑCn_:"o~pwyh4y2}9B'ɅHl12aJcdGt@Zz "V]7acv0mWsЃ~{Q]“K-Aꋱc.RlO>'jh{S2k9q5f\G2?VxCG=VWwLߛעR^2EߓJ-1ě8؛ӌ8-:*b*2OM2]Ek)2OL2=Eg4<6dvL2&]̎If$ec*zLC)cwI`(ycdPd؛dPnWtВo{:Y.(tKt\K^T3]Qz½V<=ldP^bekERw{V|譙P[+8c9WɜE愫dlU2cȌJ-2l [d"-2ȜE&۔̻ JVX%+ئTDdJ  C A? 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