Practice Check Up Survey

This information is confidential and will not be shared with a third party

PERSONAL PROFILE
Chiropractic College:	Year Graduated:
Marital Status:	Married Single Divorced Widowed
Ages of Children:	1. 2. 3. 4. 5.

Are you comfortable with the current state of balance between your practice and personal life?	Yes No
Do you ever feel burned out at the end of the week?	Yes No
How many vacation days have you experienced over the last twelve months?

If you do not change anything that you are currently doing, will you be satisfied with where your practice will be five years from now?	Yes No Unsure

What do you consider your #1 practice challenge?
What are your goals for your practice in 2007?

PRACTICE DEMOGRAPHICS
Monthly Practice Statistics:	Office Visits /mo.	New Patients /mo.
	Services /mo.	Collections $ /mo.
Give a breakdown of the following:	Health Insurance %	HMO %
	Work Comp %	Personal Injury %
	Cash %	Medicare %
	Medicade %

Are you a participating Medicare provider?

Yes No

Your top three sources for new patients last year:
Patient Referral	MD/DO Referrals	Attorney Referrals
Industrial Medicine	Lectures	Screenings
Dinners	Direct Mail	Television
Radio	Print Ads	Yellow Pages
Newspaper	Coupons	Others

What is your monthly marketing budget?

$ /month

Do your marketing and public relations programs attract the type of new patients you wish to see?	Yes No Unsure
Do you currently belong to a Practice Management Group?	Yes No
If YES, Name:
Are you interested in Patient Management Group?	Yes No

Do you practice in more than one location?

Yes No

Do You:	Office Building	Store Front	Home Office
	High Rise	Other:

Number of square ft:
How many adjusting rooms?
How many rooms are exclusive adjusting rooms?
How many hours a week do you practice?
Do you share your office with anyone?	Yes No

Number of professionals employed:	DCs MDs DOs PTs
	PTAs LMTs Other
How many total staff members:

Can your current systems handle the loss, replacement, and training of each of your key staff members?	Yes No Unsure
Do you lease/own a Spinal Decompression Table?	Yes No
Do you use/recommend nutritional products?	Yes No
If yes which one:
Would you be interested in developing a new revenue stream from your practice?	Yes No
Do you recommend orthotics?	Yes No

PATIENT CARE
Check the passive modalities you regularly include in your care plan:
Massage Therapy	Ultrasound	EMS	TENS	Heat
Cryotherapy	Paraffin	Whirlpool	Infrared	Intersegmental Traction
Interferential	Others

Do you own rehab exercise equipment?	Yes No
If yes, what equipment:

What amount of floor space is devoted to active care rehabilitation exercises?
Less than 10%	10-20%	21-30%	More

Check the active care procedures you regularly include in you care plan:
Therapeutic Exercises	Therapeutic Activities	Neuromuscular Reeducation	Manual Therapy
Massage	Activities of Daily Living	Other

Would you be interested in developing a new revenue stream from your practice?	Yes No
Do you recommend orthotics?	Yes No

FINANCES
Do you measure and monitor your practice statistics?	Yes No
Does your practice have a written patient financial policy?	Yes No
Does your practice provide a menu of financial options for your patients?	Yes No
Do you use billing software?	Yes No
Do you use electronic billing?	Yes No
Do you use an outside billing services?	Yes No
How many months of emergency budget do you have saved?
How long would your practice continue to run at its current levels of production without your presence?
Do you have a "done date" at which you wish to reach financial security?	Yes No
Do you currently have an "exit strategy" in place for when you no longer wish to practice on a full-time basis?	Yes No

COMPLIANCE
Do you use?	Travel Cards Multi-Compartment Patient File Folders Routing Slips

After how many visits are patient reexamination routinely performed?

Visits

How much time is spent (minutes) for:	New Patient Exam mins.
	Report of Findings mins.
	Re-Exam mins.

According to a nationally accredited source, in relation to what is usual and customary for you community, your fees are:

Below Average Average Above Average Unsure

When writing a diagnosis, how many diagnostic descriptions (ICD-9 codes) do you typically use?

1 2 3 4 more

Which of the following modifiers do you routinely use when billing services and procedures?

25 51 52 59 76 Unsure

How many CPT codes do you typically bill per patient visit?

1 2 3 4 more

Do you routinely link CPT codes to diagnostic descriptors?	Yes No
My practice has a designated Compliance Officer?	Yes No Unsure
My practice has a designated HIPAA Security Officer?	Yes No Unsure
My ownership and compensation agreements are Steak Officer?	Yes No Unsure
Are you confident that your documentation meets or exceeds insurance and regulatory requirements?	Yes No Unsure
Are you concerned about your current level or post-payment insurance audits?	Yes No

PERSONAL PROFILE