Skip To Content

Home / Contact / Surveys / Patient Follow Up Survey

Patient Follow Up Survey

Please check the most appropriate amount of change in your functional level from the time you were discharged from therapy to now that three months have past as related to the following areas. If the specific area does not apply to an area that you were treated for, please check off the "Never" box when available:

  1. Overall functional level:
      More functional/Improved
      Unchanged/Same
      Less functional/Worse

  2. Pain, overall endurance, range of motion, and strength:
      More functional/Improved
      Unchanged/Same
      Less functional/Worse
      Never had been a problem/goal


  3. Emotional/psychological well being/adjustment:
      More functional/Improved
      Unchanged/Same
      Less functional/Worse
      Never had been a problem/goal


  4. Cognitive abilities/memory/problem solving:
      More functional/Improved
      Unchanged/Same
      Less functional/Worse
      Never had been a problem/goal


  5. Communication skills:
      More functional/Improved
      Unchanged/Same
      Less functional/Worse
      Never had been a problem/goal


  6. Ability to care for your self/activities of daily living:
      More functional/Improved
      Unchanged/Same
      Less functional/Worse
      Never had been a problem/goal


  7. Mobility/ability to move within your environment:
      More functional/Improved
      Unchanged/Same
      Less functional/Worse
      Never had been a problem/goal


  8. Ability to complete home management, go into the community, and complete leisure activities:
      More functional/Improved
      Unchanged/Same
      Less functional/Worse
      Never had been a problem/goal


  9. Vocational/work status:
      More functional/Improved
      Unchanged/Same
      Less functional/Worse
      Never had been a problem/goal


  10. Living arrangement:
      Same as when I was discharged
      Now my living arrangement provides me with more care
      Now my living arrangement provides me with less care


  11. Patient satisfaction:

    If you were to need rehabilitative services again or if you were asked to recommend a rehabilitation facility, would you choose Schuylkill Rehab Center?
      YES, I would return or recommend
      NO, I would not return or recommend


  12. Since your discharge from Schuylkill Rehab, has your functional level been significantly decreased due to medical complications or other conditions?
      YES, new medical conditions have occurred
      NO, no new medical conditions have occurred since my discharge

Comments:
 
Optional:
Name: Phone: