Practice Mini Checkup

Your Personal Information

Doctor

Office Phone

Home Phone

Cell Phone

Fax Number

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 explain your fees. Why are they the way they are?

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

Why do you think patients do not stay with you?

Do you know why you are not having many NP's/referrals?

What is the aim of your care?

Do your patients understand it?

Are they 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?

Einstein once said, "Nothing changes until something moves." What would it take to move you?

Why are you completing this questionnaire?

If I were to teach you how to explode your practice by 30-50 new patients/month, are you willing to make the necessary alterations in your practice and yourself? ...And it is all incredibly honest and ethical so you need not be concerned in the least.

On a scale of 1-10, please rate your level of commitment

How can I help you as a 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