In-Practice Evaluation Questionnaire

* Indicates a required value

First Name

Last Name

Address Line 1

Address Line 2

City

State

ZIP

Home Phone

Work Phone

Length of Time at Present Location(s):

Have You Practiced Before?
Yes No
(if so where?)

How Long & Why Did You Change Location?

Have You Ever Had Your License Revoked or Suspended?
Yes No
(if yes explain:)

How Did You Hear of DrFernandez.com?

Have You Ever Attended a DrFernandez.com Seminar?
Yes No
(if yes where and when?)

Chiropractic Background

Are You Presently Enrolled in a Chiropractic
Management or Consulting Course of Instruction?
Yes No
(if yes please list)

Have You Ever Been Enrolled in a Management
or Consulting Course in the Past?
Yes No
(if yes please list)

Do You Consider Your Energy Level:
Low
Good
High

How Much More do You Want to Take Home Per Year?

Have You Ever Declared Bankruptcy?
Yes No

Facilities & Location

Are You in Full Time Practice?
Yes No
(if no please explain)

Number of Square Feet in Your Office?
0-1000
1000-1500
1500-2000
2000-3000
over 3000

What Is the Ratio of D.C.’s to Population in Your Town?
(Divide the Number of D.C.’s into the Approximate Population of Your Town)

Do You Think You Should Change Towns,
or Locations Within Your Present Town?
Yes No
(if yes why?)

Equipment Evaluation

How Many Adjusting Rooms Do You Utilize?

Are All Adjusting Rooms Identically Equipped?
Yes No
(if no please describe the difference)

Do You Adjust Patients on the First Visit?
Yes No

Do You Give Periodic Examinations to
Check Your Patients’ Progress?
Yes No

What Type of Adjustments Do You Give?
(Flexion distraction, drop table, Gonstead, etc.)?:

Do You Use Food Supplements?
Yes No

Do You Perform or Order Blood or Urine Chemistries?
Yes No

Do You Use Orthopedic Collars, Supports or Pillows?
Yes No

Do You Do Any Personal Injury Work?
Yes No

Do You Have a Procedure to Prevent Patients
from Terminating Care Prematurely?
Yes No
(if yes please explain)

Number of Square Feet in Your Office?
0-500
500-1000
1000-2000
2000-3000
over 3000

Do You Have a Recall System?
Yes No

What Type of Advertising Do You Do?
Television
Radio
Newspaper
Telemarketing
Yellow Pages
Other :

How Else Do You Attract New Patients to Your Office?

Do You Send out Newsletters?
Yes No

Do You Send out Birthday Cards?
Yes No

What Income Production Do You Have When You Are out of the Office?

Are You Doing Duties in Your Office
Which Could Be Done by Someone Else?
Yes No
(if yes please describe)

What Problems, Procedures, or Situations
Do You Feel Have Hindered Your
Practice Growth And/or Income?

Financial

What Do You Charge for Your Services?
Adjustments?
Physiotherapy?
14 X 36 X-rays?
14 X 17 X-rays?
8 X 10 X-rays?

What Percent of Your Practice Is:
Cash?
Insurance?
Workers' Comp?
Personal Injury?
Prepaid (Series-Case)?

What is Your Monthly Overhead?

Practice Analysis

Please Complete the Following Information For the Prior 6 Months of Your Practice:

Total # of Missed Appointments

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Total # of Patient Visits

Total # of New Patients

Total Money Collected

Total Services Billed

Total # of Reactivated Patients

Do You Practice by Appointment?
Yes No

Do You Charge for All of Your Services?
Yes No
(If No, Which Services Don’t You Charge For?)

Clerical Staff

Do You Have a Receptionist?
Yes No
Approximate Age:

Number of Square Feet in Your Office?
Less Than 1 Year
1-2 Years
2-5 Years
5-10 Years
Over 10 Years

Rate Your Receptionist:

As a Collector
Good Fair Poor

On the Telephone
Good Fair Poor

Typing & Office Skills
Good Fair Poor

Willingness to Work
Good Fair Poor

Personal Appearance
Good Fair Poor

General Health
Good Fair Poor

Enthusiasm About Chiropractic
Good Fair Poor

Do You Feel You Should Replace Your Receptionist?
Yes No
(If Yes, Why?)

Does Your Spouse Work For You?
Yes No
(If Yes, in What Capacity?)

(If No, Would You Like Her to Work For You?)

Do You Have Any Other Staff Assisting You In the Office?
Yes No
(If Yes, How Many and What Are Their Duties?)

Collections

Do You Have A Collection Problem in Your Office?
Yes No
(If Yes, Explain What You Believe the Cause Is:)

Estimate the Amount of Your Accounts Receivable:

Practice Problems

Have You Recently Thought of Getting Out of Chiropractic?
Yes No
(If Yes, Why?)

In Which of the
Following Areas Do You Feel You Need Help?

Consultation	Examination Procedures	Report of Findings
Referrals	Insurance Procedures	Advertising
Increased Income	Personal Injury Practice	Associate Doctor Practice
Staff Acquisition	Staff Training	Staff Management
Location Evaluation	Sign Evaluation	Floor Plans
Overhead Control	Money Management
Other:

Summary

What Assistance Would You Like From DrFernandez.com?

What Type Services Do You See Yourself Offering in the Future?

If you are married, please have your spouse answer the questions below.
If you are single, scroll to the bottom and click submit.

Chiropractic Spouse’s Questionnaire

Name:

How Long Married?

What Are Your		What Are Your Spouse’s
Assets?
Weaknesses?
Desires?

What Can DrFernandez.com Do to Help You?

What Can DrFernandez.com Do to Help Your Spouse?

Are You Willing to Assist Your Spouse to Go The Extra Mile in Practice?
Yes No
(If Yes, Why?)

Do You Have Any Restrictions on Your Spouse’s Time?
Yes No
(If Yes, What?)