Patient Survey Your Name (optional) Your Email (optional) *1. Age: ---Under 1818-3031-4546-6060+ *2. Gender: ---MaleFemale *3. What town are you from: ---CumberlandBarronBarronettCameronClaytonLuckRice LakeShell LakeSpoonerTurtle LakeOther *4. What was the purpose of the visit: ---Neck PainHeadachesLow Back PainShoulder PainWhiplash injurySciaticaWellnessOther *5. What Chiropractor did you see: ---Dr. Tom ToftnessDr. Jodi Griffith *6. Ease of making an appointment: ---ExcellentGoodFairPoor *7. Prompt return of calls: ---ExcellentGoodFairPoor *8.Time in waiting room: ---ExcellentGoodFairPoor *9. Time in treatment room: ---ExcellentGoodFairPoor *10. Chiropractor took enough time with you: ---ExcellentGoodFairPoor *11. Chiropractor explains your condition to you: ---ExcellentGoodFairPoor *12. Chiropractor explains exercises and activities to help my condition: ---ExcellentGoodFairPoor *13. All the staff was friendly to you: ---ExcellentGoodFairPoor *14. Cost of services: ---ExcellentGoodFairPoor *15. Explanation of the charges: ---ExcellentGoodFairPoor *16. Was the clinic neat and clean: ---ExcellentGoodFairPoor *17. Was the clinic easy to find: ---ExcellentGoodFairPoor *18. Do you feel there was adequate privacy: ---ExcellentGoodFairPoor *19. Would you refer friends or relatives: ---YesMaybeNo 20. What did you like best about our clinic 21. What did you like least about our clinic Additional Information