Practice Mini Checkup

Your Personal Information

Doctor

Office Phone

Home Phone

Cell Phone

Your Email

What do your patients call you?

Your Practice Information & Goals

What is your mission? Why do you do what you do?

Why did you become a chiropractor?

Average new patients each month:

Average patient visits in a week:

My percentage of children is:

<5%

5-10%

10-20%

20-30%

30-40%

>40%

How many patient per week would you like to be seeing?

In 6 months?

In 12 months?

Please describe your ideal practice. What would it be like?

I would like to increase my gross income by $_____ in the next 12 months.

Your Thoughts

Do your patients stay through corrective care to wellness care?

Are you primarily referral based, if not why not?

What is the aim of your care?

Do your patients understand it and are in agreement with you?

Your practice is a reflection of you. Is there anything else going on in your life?

What do you consider to be your biggest obstacle?

What will it take for you to take decisive action?

Why are you completing this questionnaire?

If I were to teach you how to explode your practice by 15-30 new patients/month, are you willing to make the necessary alterations in your practice and yourself?

On a scale of 1-10, please rate your level of commitment to becoming the best doctor you can be

How can I help you as your coach?

What are your expectations?

What is holding you back?

How will you conquer it?

One last thing; How did you hear of Dr. Kristina?

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Practice Mini Checkup

Your Personal Information

Your Practice Information & Goals

How many patient per week would you like to be seeing?

Your Thoughts