PRACTICE ANALYSIS SURVEY

PRACTICE PERFECT PERSONAL PROFILE
Date: M: / D: / Y:
First Name: Last Name:
Practice Name:
Primary Office Address:
City: State: Zip:
Office Telephone: ( ) - Office Fax: ( ) -
EMail Address: Website: www.
 
DEMOGRAPHICS
Practice Stats:
Monthly: Office Visits: New Patients: Billing: $ Collections: $
Your Current Montlhy Income: $
 
OFFICE DESCRIPTION & OPERATIONS
Type of Offices: Office Building Store Front Home Office High Rise Building Other:
Number of Square Feet: Office 1: Office 2: Office 3:
What is the total monthly overhead expense for each location?
Office 1: Office 2: Office 3:
Do you own the building of your practice?: Yes No
How many hours a week do you work?: hours.
How many staff members: 1 2 3 4 5 6 7 8 9 10 Other:
How many full-time assistants at your front desk?:
Do you use: Travel Card System Routing Slip
Do you pull patient files on every office visit?:
Yes No
Do you have a menu of financial options for your patients?:
Yes No
Do you have a written financial policy?:
Yes No
Do you record daily office stats?:
Yes No
How many cancellations/month?: How many reschedule?:
Do you track missed patient appointments?:
Yes No
Do you perform regular re-examinations?:
Yes No        If YES, how often?: Every visits.
How much time is spent (minutes) for:       Exam:     Report of Findings:      ReExaminations:
Do patients escort themselves to the adjusting rooms?:
Yes No
How many DCs / MDs / DOs?: 1 2 3              DC MD or DO?: DC MD DO
How many adjusting rooms?:               How many exam rooms exclusive of adjusting rooms?
Do you have in-office x-rays?: Yes No Automatic Processor Hand Tanks
Do you xray all your patients: Yes No Most
Who reads your films?: Myself Outside Radiologist
Do you have a dedicated room for patient education?:
Yes No
Do you have Physical Terapist?:
Yes No
Do you have a Physical Therapist Aid?:
Yes No
How many Massage Therapists do you have?:
What percentage of your patients receive therapy/modalities on each visit?: %
Mark the modalities that you use:
US
EMS
TENS
Heat
Cryotherapy
Paraffin
Whirlpool
Infrared
Intersegmental Traction
Interferrential
Other:
Have you ever done diagnostic work in your office?:
Yes No
If YES, do you own the diagnostic equipment or use an outside service? : I own the equipment I use an outside service
If YES, how much billing per month?: $              Collections per month?: $
Check the diagnostics you own:
SEMG
SSEP
NCV
EMG (needle)
EEG
ECG
EKG
Neurometer:
Other:
Have you ever done blood work?:
Yes No
Do you have a lab set up?:
Yes No
Give a breakdown of percentages of the following:
PI: %
Workers Comp: %
Cash: %
Health Insurance: %
Medicare: %
HMOs: %
Are you a participating Medicare Provider?:
Yes No
What is your source of new patients?:
Yellow Pages
Dinners
Screenings
PI Attorneys
Patient Referrals
TV
Direct Mail
Newspaper Ad
MD Referrals
Newsletters
Other:
Monthly budget for advertising: $
Types of advertising you use:
Newspaper
Coupons
Radio
TV
Spinal Screening
Other:
Do you belong to a Practice Management Group?:
Yes No
If YES, Name:
Are your needs being met?: Definitely Somewhat Not at all
If NO, have you ever been a member of a practice management organization?:
Yes No
 
PERSONAL
Martial Status: Married Single Divorced Widow
Chiropractic College: Year Graduated:
Type of practice: Sole Practicioner Partnership Corporation
Do you:     Practice Full Time     Practice Part Time     Manage Part Time     Manage Only
Do you practice in more than one office?:
Yes No
Do you share your office with anyone?:
Yes No
Are consistently treating the volume of patients you would like to?:
Yes No
Are you consistently getting the amount of new patients you want?:
Yes No
Are you consistently making the money that you feel you deserve?:
Yes No
Is your staff trained so that when you're out of the office you trust the job is being done correctly?:
Yes No
Do you feel a balance between your home life and practice life?:
Yes No
Are you taking the amount of time off per year that is necessary for you to stay rested and focused?:
Yes No
Do you have patients stopping care prematurely?:
Yes No
Do patients regularly refer their families and friends to your practice?
Yes No
Do you retain staff long term?:
Yes No
Do you feel you have control over your finances?:
Yes No
Do you have a minimum of three months of personal and one month of practice overhead saved in case of injury or sickness?
Yes No
Do you believe your practice growth is reflective of your personal growth?
Yes No
Do you feel your goals are in alignment with your current actions?:
Yes No
If your practice is stuck or has hit a plateau do you think it is due to your procedures?:
Yes No
Or do you think it is because of your current personal skill set?:
Yes No
Do you realize that having a coach/consultant will increase your chances of success and fulfillment?:
Yes No
Will you try new things if what you're doing isn't working?:
Yes No
May we call you to set up an appointment to speak to Dr. Dahan?:
Yes No

"The time is always right to do what is right."