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21 Keys Questionnaire for Doctors Already in Practice

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New Member Questionnaire

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Let's Get Started!
We're going to ask some basic questions about your practice over the next few pages, many of which are simple yes/no answers. First, let's make sure we have all your contact information correct.
Name*
First Last
Clinic Name
Office Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Office Phone*
Fax
Mobile Phone*
Email*
Date of Birth*
Month
Day
Year
How did you hear about us?*
If you heard about us from another doctor, please let us know their name.
Fantastic!
Next we're going to ask a little about your chiropractic background.

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Chiropractic Background
Tell us a little more about yourself and your training.
What school did you graduate from?*
What year did you graduate?*
Have you recently thought about getting out of chiropractic?*
- Yes
- No
Why have you thought about getting out of chiropractic?
Have you ever been with a chiropractic management course or instruction?*
- Yes
- No
Which management courses or instruction have you taken?
This doesn't need to be a complete list. Just tell us the highlights you think are important.
Great Progress!
You're doing great! Next we're going to ask a bit about your facilities and location.

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Facilities and Location
Tell us how your office and location are set up.
What is the approximate square footage of your practice?*
Do you share common office facilities with any other Chiropractor or Professional?*
- Yes
- No
Do you have more than one office location?*
- Yes
- No
Awesome! Keep at it!
Next we need to see where your office is financially. Don't worry, this is only to help us understand your practice and will be kept in strictest confidence.

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Financial Information for the past three months
If you need to look up this information and come back later you can always use the "Save and Continue Later" button at the bottom of this page. If you do, we'll send you an email link you can use to pick up right where you left off when you return. This is the biggest section, but it's crucial that we know how your business is doing to best understand how to help.
Financial Information for last month
This is the last full month you have information on. These numbers don't need to be to the penny, but more accurate information will help us better understand your practice.
What was your total monthly overhead/expenses last month?*
What was your total in services last month?*
What was your total in collections last month?*
How many patient visits did you have last month?*
How many new patients did you have last month?*
Financial Information for two months ago
What was your total monthly overhead/expenses two months ago?*
What was your total in services two months ago?*
What was your total in collections two months ago?*
How many patient visits did you have two months ago?*
How many new patients did you have two months ago?*
Financial Information for three months ago
What was your total monthly overhead/expenses three months ago?*
What was your total in services three months ago?*
What was your total in collections three months ago?*
How many patient visits did you have three months ago?*
How many new patients did you have three months ago?*
Whew, you made it!
There's just one last question about your financials.
Do you perform other ancillary services, such as: nutrition, orthotics, massage, etc.?*
- Yes
- No
Moving on
Next, let's do a quick head count in your office.

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Office/Clerical Staff
How many full time staff members do you have?*
How many part time staff members do you have?*
Almost done!
To wrap up, we're going to ask a few final questions about your practice.

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Your Practice
These questions help us determine if there are any areas we should help you focus on.
Do you currently operate a cash practice?*
- Yes
- No
Are you currently having issues with third-party payers?*
- Yes
- No
What diagnostic equipment do you have?*
What interests you the most?*
- Pain based practice? (Personal Injury)
- Wellness care based practice?
- Traditional subluxation based practice? (Chiropractic only)
What are your motivating factors for applying to be part of the program? (check all that apply)
- Learn to work smarter not harder (i.e. more efficient to reduce workload)
- New patient acquisition via marketing and/or referral programs
- Increase net revenue
- Increase patient compliance/retention to overall recommendations (improving patient communication and perceived value)
What percentage of your practice is made up by:
Chiropractic Percentage (%)
Please enter a number from 0 to 100.
Nutrition Percentage (%)
Please enter a number from 0 to 100.
Functional Therapies Percentage (%)
Please enter a number from 0 to 100.
Other Percentage (%)
Please enter a number from 0 to 100.
Which of those are you most interested in increasing it’s value in your practice?*
- Chiropractic
- Nutrition
- Functional Therapies
- Other
If nutrition/functional medicine plays a part in your practice what kind of monthly inventory expense or capital equipment expenditure has that added to your overhead?
Would you be willing to participate by reporting statistics, attending Boot Camps, visiting training centers, and opening your office for evaluation?*
- Yes
- No
Success!
Hit that submit button below to package up your answers and send them off to us!

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“You Will Know Them By Their Fruits”

MATT. 7:16

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