* Indicates a required value..
Email
First Name
Last Name
Address Line 1
Address Line 2
City
State
ZIP
Home Phone
Work Phone
* Length of Time at Present Location(s) OR ANYWHERE:
* 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?)


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