PA Pain & Spine Patient Survey
Thank you for being a patient at our practice! In an effort to better support our patients, we are asking for your participation and feedback in completing the following survey. Thank you for your time in completing this fully - 2 participants will be randomly chosen to receive a special prize for participating so be sure to put a valid email address! Thank you! *Deadline: 12/23.
Please Enter your VALID Email
*
example@example.com
Please Enter your Age
*
How did you hear about our practice?
*
Google
Social Media
Patch.com
Family/Friend
Bucks County Herald Senior Living
Bucks County Courier
Doylestown Living Magazine
Counties Alive
Referring Doctor Office
Home Mailer
Online Advertisement
Welcome Wagon
Event
Other
How long have you been a patient with PA Pain and Spine?
*
Less than 1 year
1-2 years
3-4 years
5 years or more
What office location do you primarily visit?
*
Quakertown
Chalfont
What town do you currently reside in?
*
Please Select
Doylestown
Lansdale
Souderton
Chalfont
Quakertown
Bethlehem
Sellersville
Collegeville
Royersford
Harleysville
Horsham
Hatboro
Ambler
Willow Grove
Telford
Perkasie
North Wales
Montgomeryville
Philadelphia
Allentown
Blue Bell
Warrington
Warminster
Easton
Bethlehem
Hatfield
Pennsburg
East Greenville
New Hope
Other
Why did you come to see us? (Select all that apply)
*
Back Pain
Neck Pain
Joint Pain
Muscle or Tendon Pain or Spasming
Abdominal Pain
Nerve Pain or Injury
Medical Marijuana
Migraines
TMJ Disorder
Pelvic Pain
Interstitial Cystitis
Regenerative Treatment
Specific Procedure
Injury
Other
What Procedures or Treatments have you experienced with our practice? (Select all that apply)
*
Trigger Point Injections
Nerve Blocks
Joint Injections
Radiofrequency Ablation
Epidural or Spinal Injections
Medical Marijuana Certification
PRP Regenerative Therapy
Intradiscal PRP
Stem Cell Treatment Regenerative Therapy
Prolotherapy
Spinal Cord Stimulator Trial
Spinal Cord Stimulator
Pain Pump Implant
VIA Disc Procedure
SPRINT Procedure
MILD (Minimally invasive lumbar decompression) Procedure
Vertiflex Spacer
Minimally Invasive SI Joint Fusions
Kyphoplasty
Peripheral Nerve Stimulators
Other
What level of weekly activity and function were you at PRIOR to receiving treatment with us?
*
Not Active or Functioning
1
2
3
4
Very Active and Normal Functioning
5
1 is Not Active or Functioning, 5 is Very Active and Normal Functioning
What level of weekly activity and function are you at AFTER receiving treatment with us?
*
Not Active or Functioning
1
2
3
4
Very Active and Normal Functioning
5
1 is Not Active or Functioning, 5 is Very Active and Normal Functioning
How would you rate your consultation experience with our clinical team?
*
1
2
3
4
5
1 = not helpful, 5 = Very helpful
How would you rate your treatment/procedural experience with our clinical team?
*
1
2
3
4
5
1 = Not Helpful, 5 = Very Helpful
How well do you feel you understand your treatment plan?
*
Not Well
1
2
3
4
Very Well
5
1 is Not Well, 5 is Very Well
What Physician Assistant do you primarily see?
*
Please Select
Amanda Hyland
Jennifer DellaGuardia
Judy Le
Lauren Bruce
Tara Dupre
How would you rate your experience with our Physician Assistant/Associate (PA ) staff?
*
1
2
3
4
5
1 = could be better, 5 = Excellent
What Physician do you primarily see?
*
Please Select
Dr. Qu
Dr. Kelly
Dr. Bozak
Dr. Acharte
Dr. Boyd
How would you rate your experience with our Physician Staff?
*
1
2
3
4
5
1 = could be better, 5 = Excellent
How would you rate your experience with our Medical Assistant Staff (the first person who brings you back and discusses your updates)?
*
1
2
3
4
5
1 = could be better, 5 = Excellent
How would you rate your experience with our FRONT DESK Staff at either location?
*
1
2
3
4
5
1 = could be better, 5 = Excellent
How would you rate your experience with our Call Center & Billing Staff?
*
1
2
3
4
5
1 = could be better, 5 = Excellent
Are there any medical assistants or other staff members that have been particularly great, or helpful to you?
How easy/quickly do you feel you are able to schedule an appointment with one of our team members?
*
Not Easy - scheduling too far out
1
2
3
4
Very Easy - able to get appointments when I need them
5
1 is Not Easy - scheduling too far out, 5 is Very Easy - able to get appointments when I need them
If you have had an issue at our practice, how well do you feel it has been resolved?
Not resolved well
1
2
3
4
Issue was completely resolved
5
1 is Not resolved well, 5 is Issue was completely resolved
Where do you look to find updates about us? (Select all that apply)
*
Email
Website
Facebook
Instagram
Google
Other
How would you prefer to schedule your appointments?
*
By Phone
Online/through patient portal
How do you prefer to make balance/bill payments? (Select all that apply)
*
In Person
Online/through patient portal
By Phone
Have you ever purchased any of the following items from our office? (Select all that apply)
*
CBD Lotion
CBD Tincture
CBD Gummies
None of the above
What events/offerings from our practice would you be interested in? (select all that apply)
*
Procedure information and educational events
LIVE stream informational seminars
Health & Wellness Fairs
Community Events - Veterans Day
Educational Blogs
Ability to purchase PA Pain and Spine Retail Items
None of the Above
Other
What do you wish our practice offered that we currently do not?
How does our practice compare to other practices you may go to?
What other feedback or comments do you have for our team?
Submit
Should be Empty: