FREE
Dental Practice Fitness Questionnaire
Please enter your email
address (where you want the results of your diagnosis sent).
Your email:
(required)
TEMPERATURE
1.
How many new patients does
your practice average each month?
5
10
15
20
25
30
35
40
more than 40
don't know
select
2.
Which of the following do
you use to market your practice? (select
all that apply)
3.
In the past year, how many
employees have quit or been let go due to not having the “correct
fit” with your practice?
0
1
2
3
4
5
6
7
8
9
select
PULSE
4.
Please check all of the
areas listed below that you feel the office could benefit
from having renovated or reorganized:
5.
Do you have daily huddles?
select
every day 30 min+
every day 20 min
every day 10 min
most days
once in a while
no, never
6.
Do you schedule and have Staff
Meetings:
select
1x/week
1x/2 weeks
1x/month
1x/3 months
sometimes
rare or never
7.
Does your office partake
in Continuing Education?
select
regularly &
frequently
occasionally
haphazardly
CE not typically provided by
the office
each staff member completes
on own
Do you share new
information, cross-train each other and make sure you have
common knowledge on all dental concepts?
8.
Please check all of the
areas listed below that you feel the office could benefit
from having:
9.
Which areas is your office
accomplished in?
Daily Doctor's
Production $5000-$6000
select
doing well
need help
Daily Hygiene Production
$100-$1500
select
doing well
need help
Financial Arrangements
& Case Acceptance
select
doing well
need help
Personality Typing our
Patients
select
doing well
need help
Inter-office Communication
select
doing well
need help
Common Office Philosophy
on over-the-counter Dental Products
select
doing well
need help
RESPIRATION
10. What
is your average acceptance rate for Restorative Cases?
select
greater than 85%
greater than 50%
lower than 50%
don't know
11. What
is your average acceptance rate for Root Planing Cases?
select
greater than 85%
greater than 50%
lower than 50%
don't know
How many
Root Planning appointments do you average per day
12. What
is your average monthly collection rate?
select
90-98%
80-89%
70-79%
60-69%
60% or below
don't know
13. Do
you offer a Pre-Payment option?
Yes
No
14. Is
every team member (excluding the Doctor), comfortable with
presenting Financial Arrangements and collecting money?
Yes
No
15
. What is your yearly gross
Production? (If you like to keep this
confidential, please do not answer this question.)
select
1,000,000+
800,000-1,000,000
600,000-800,000
400,000-600,000
200,000-400,000
don't know
16.
Do you accept PPOs?
17. Do
you accept HMOs?
HEART
RATE
18.
In the past year has your
office participated in any of the following areas of study?
OSHA Compliance & Update
19.
How many cancellations
do you have on average in your daily schedule?
In Hygiene Schedule?
select
1
2
3
4
5
more than 5
In DDS Schedule?
select
1
2
3
4
5
more than 5
How many of these do
you recover
select
1
2
3
4
5
all
20.
Do you routinely use
the following:
Informed Consent Forms
Medical History Updates
(1x/year)
HIPAA Clearance Forms
OSHA Weekly/Monthly &
Yearly Compliance
Financial Arrangement
(signed) Form
Financing Options (i.e.
Dental Fee Plan)
Phased Treatment Tracking
Form
Hygiene Tracking System
Recare System
Have you ever worked
with a Practice Management Company?
If so,
name of organization
Do you feel you are
making enough money?
Do you feel you are
maximizing your use of time?
Do you have enough
time off from the practice?
Thank you for taking the time to complete the questionnaire.
Please click “Diagnosis” and we will email your
results shortly.
