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Surveys
2010
February
D
Dr. Nordt's Knee Follow Up
Dr. Nordt's Knee Follow Up
From the office of
William E. Nordt, III, M.D.
Thank you for choosing Dr. Nordt and West End Orthopaedic Clinic for your recent knee surgery. Dr. Nordt would like to know how you are doing post-operatively. Your responses to the questions below are greatly appreciated.
On a scale from 1 to 10, where
1=Very Disappointed
and
10=Very Pleased
, please indicate your level of
satisfaction
with the results of your surgery.
Very Disappointed
2
3
4
5
6
7
8
9
Very Pleased
On a scale from 1 to 10, where
1=Cannot Perform Daily Activities
and
10=No Limitation in Activities
, please rate the
function
of your knee...
Cannot Perform Daily Activities
2
3
4
5
6
7
8
9
No Limitation in Activities
BEFORE
surgery:
AFTER
surgery:
Would you like to be contacted for a follow up appointment?
-- Select --
YES
NO
If you answered "YES" to the question above, please provide us with your contact information:
First Name
:
Last Name
:
Phone
:
Email Address
:
We appreciate any comments you may have:
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