Is your schedule unpredictable and do you have days where the time was never filled on the schedule?	YES NO
Do you have written "how to" training manuals for your staff?	YES NO
Are patients getting confirmed and still breaking their appointments?	YES NO
Are patients with incomplete treatment being contacted on a regular basis?	YES NO
Are you producing and collecting according to your goals?	YES NO
Are you achieving your personal financial goals?	YES NO
Are you in control of your practice and its future?	YES NO
Do you look forward to going to the office?	YES NO
Is your collection to production ratio at least 98%?	YES NO
Do you rarely get complaints about mistakes on patient's accounts?	YES NO
Does your staff know exactly what you want from them?	YES NO
Do you have time to train your staff?	YES NO
Are newly hired staff trained quickly and soon functioning well on their jobs?	YES NO
Do you know how productive your staff is on an individual basis?	YES NO
Is staff morale in your practice very high?	YES NO
Is there a high rate of staff turnover?	YES NO
Is there conflict between employees?	YES NO
Is your office in a stand-alone building?	YES NO
Has your production leveled off or declined?	YES NO
Is your office sign visible to passersby?	YES NO
Have you done any marketing to attract new patients?	YES NO
If so, what type specifically?
What is the number of dentists per capita in your town/city?

What was your total office production last year?	$
What percentage of total office production were hygiene procedures?	%
What were your total office collections last year?	$
What is the average percentage of production collected each month?	%
# of Administrative/Front Desk Staff	FULL TIME PART TIME
# of Hygienists	FULL TIME PART TIME
# of Technical Staff (not including Hygienists)	FULL TIME PART TIME
# of Doctors in the practice
# of Doctor Treatment Rooms
# of Doctor Hours Per Week
# of Hygiene Treatment Rooms
# of Combined Hygiene Days Worked Per Week
# of New Patients Per Month
Do Patients have to wait 3 or more weeks for an appointment?	YES NO
How many patients have not been in for a cleaning in 6 months or longer? Go back 3 years.
What % of your Accounts Receivable balance is over 90 days?	%
What is your total outstanding Accounts Receivable balance?	$
Are Hygiene salaries more than 33% of their production?	YES NO
What percentage of your collections was spent on the following last year:
Facility Cost?	%
Total Staff Compensation (including benefits)?	%
Continuing Education?	%
Marketing?	%
Laboratory Cost?	%
Office Administrative Supplies?	%
Technical Dental Supplies?	%
What is your overhead percentage (all expenses, except Dr.'s salary)?	%

Does your spouse work with you in the practice?	YES NO
If so, what is your spouse's job position?
Is your spouse full-time or part-time?	FULL PART
Do you have trouble finding/hiring qualified staff?	YES NO
Do you have trouble retaining staff?	YES NO
Do you have a policy manual for employees?	YES NO
In order, list what you perceive to be your biggest problems NOW. 1. 2. 3.

Have you ever had a practice management consultant?	YES NO
If so, describe the type of program (consulting, seminars, one-on-one, on-site, etc.)
Were you satisfied with the results?	YES NO

Do you have retirement goals?	YES NO
If so, what are they?
Do you feel you are on track to meeting them?	YES NO
Is there something you feel you should do to be more on track?	YES NO
If so, what might that be?

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