The Questionnaire
Exhibit #2Survey Questionnaire
(Please complete in returned within five days.)
1. Name:___________________
(optional)
2. Address ___________________ phone #_____________:
(optional) (optional)
3. Age: Circle one of the following:
10 -- 19 years 20 -- 29 years 30 -- 39 years
40 -- 49 years 50 or above
4. Presenting problem: Circle one or more of the following:
Anxiety Panic Attack Agoraphobia
Depression Phobia
5. Circle approximate number of sessions at biofeedback center:
1 -- 2 3 -- 5 6 -- 10 11 -- 15 16 or more
6. Several time you had symptoms before consulting biofeedback:
Less Than Three Months Four to six months
Six months to a year Year to five years
7. Since your initial time at the biofeedback center have you returned for maintenance or follow-up visits?
Yes______ No______
if yes, the feel they have been effective in enabling you to achieve your goals? Yes______ No_______
explanation (if desired)
8. List any other therapy is you may have consulted prior to biofeedback for the same presenting problem. (Optional)
9. The subsequent therapies, if any, you may have consulted for the same presenting problem. (Optional)
10. I have stopped attending the biofeedback center for my presenting problem listed above because: a. Treatment no longer required, b. Didn't feel treatment was effective, c. Lack of funds, d. Lack of time, e. Too far to travel, or f. Other
11. If you selected (c), above -- lack of funds because: a. No health insurance available, b. Health insurance you had didn't cover services, c. Lack of money
12. Please evaluate the following statement:
Strongly Mildly Mildly Strongly
Agree Agree Agree Uncertain Disagree Disagree Disagree
1 2 3 4 5 6 7
A. I found the staff courteous and helpful at all times.
B. I found the environment professional and up-to-date.
C. the appointments were kept promptly.
D. the counselor that work with me was knowledgeable and conveyed to me a sense of confidence.
E. telephone contacts with the facility were easy to make.
F. concerns regarding appointment changes or billing were handled courteously and without delay.
G. The sessions I had were insightful and very useful for managing my life.
H. My sessions at the biofeedback center enable me to free myself of the presenting problem(s) Circled in item #4 on page #1.
I. Since I have completed my sessions at biofeedback, I am able to manage my life effectively and stay relatively free of the presenting problem(s) listed in item #4 on page #1.
J. I would gladly recommend services at the Biofeedback Center to a friend suffering from a similar stress -- related problem.
K. the fees were appropriate in what I would expect.
L. Cassette tapes, ever given along with the sessions, were effective in very useful.
M. The facility was center located in easy to get too.
Other comments:
click here to view raw data from questionnaire