Client Inventory

CLIENT INVENTORY

F I V E S T A R M A N A G E M E N T

Seattle Office: 2301 NE Blakeley Street Ste 102, Seattle, WA 98105 Telephone 800-224-4876 Fax 206-322-0457

Instructions: Please answer each question in as much detail as possible and e-mail to:nd return to the Five Star-Seattle office within ten days of receiving this information. This information is vital in assessing your needs and the ways we can best help you.

Please make a copy of the completed inventory for your records prior to returning it to Five Star-Seattle!

1.Personal

Today’s Date Date of Birth Age Your Height/Weight

1.1Doctor’s Name

1.2Clinic Name

1.3Clinic Address

1.4City, State Zip

1.5Office Phone () Office Fax ()

1.6Home Phone () Cell Phone ()

1.7E-mail Address Alternate ClinicE-mail Address

1.8Spouse’s Name

1.9Children (Names and ages) , , , , ,

1.10What organized high school or college sports did you participate in?

1.11Do you currently exercise? Yes No What type and frequency of exercise(s)/sport(s) do you do?

1.12What hobbies or outside interests do you currently enjoy?

1.13From what chiropractic college did you graduate?

1.14How many total years in practice?

1.15Please write a brief practice history (i.e. where, when and with whom):

1.16List any management seminars you have or are currently participating in. Please list them in order, with the dates you were involved, and rate each on a 1 to 10 scale (1 being poor, 10 being excellent).

A. From To Rating

B. From To Rating

C. From To Rating

D. From To Rating

E. From To Rating

F. From To Rating

G. From To Rating

2.Clinical

Your First Day New Patient Procedure

2.1Please give a step by step description of your first visit for a new patient. What is the total time for this visit as measured by Doctor? And as measured by C.A.?

Your Second Day New Patient Procedure

2.2Please give a step by step description of your second visit for a new patient. What is the total time for this visit as measured by Doctor? And as measured by C.A.?

Your Regular Patient Visit Procedure

2.3Please give a step by step description of your regular visit for a returning patient. What is the total time for this visit as measured by Doctor? And as measured by C.A.?

Your Technique

2.4Please give a description of your technique and any specialties you may have, including therapies, in sequence. (Your routine adjustment.) What is the total time for this visit as measured by Doctor? And as measured by C.A.?

2.5Do you examine all patients? Yes No. If no, who don’t you examine and why?

What is the total time for this visit as measured by Doctor? And as measured by C.A.?

2.6Do you x-ray all patients? Yes No. If no, who don’t you x-ray and why?

What is the total time for this visit as measured by Doctor? And as measured by C.A.?

2.7What percentage of your patients receive a re-exam? Do you charge for the re-exam?

2.8At what point do you re-examine?

2.9How do you know when the re-exam needs to be done?

2.10What percentage of your patients receive therapy? Do you charge for therapy?

2.11How do you know when therapy needs to be started or discontinued?

2.12What percentage of your patients receive a re-x-ray? Do you charge for the re-x-ray?

2.13At what point do you re-x-ray?

2.14How do you know when the re-x-ray needs to be done?

3.Staff

Note: Please list and rate all employees, including associates and C.A.s, both full time and part time. If your spouse, relatives or any special people work for you, please indicate their relationship to you.

3.1Name: Title: Length of Employment:

Monthly Pay: Bonus Pay: Salary: Hourly: Contract Labor:

General Duties:

Hours Required to Work Per Week: Typing W.P.M.: 10-Key By Touch:

Computer Experience (Training/Hours):

Seminars Attended:

Other Skills:

Doctor’s Personal Evaluation:Poor 1 2 3 4 5 6 7 8 9 10 Excellent

3.2Name: Title: Length of Employment:

Monthly Pay: Bonus Pay: Salary: Hourly: Contract Labor:

General Duties:

Hours Required to Work Per Week: Typing W.P.M.: 10-Key By Touch:

Computer Experience (Training/Hours):

Seminars Attended:

Other Skills:

Doctor’s Personal Evaluation:Poor 1 2 3 4 5 6 7 8 9 10 Excellent

3.3Name: Title: Length of Employment:

Monthly Pay: Bonus Pay: Salary: Hourly: Contract Labor:

General Duties:

Hours Required to Work Per Week: Typing W.P.M.: 10-Key By Touch:

Computer Experience (Training/Hours):

Seminars Attended:

Other Skills:

Doctor’s Personal Evaluation:Poor 1 2 3 4 5 6 7 8 9 10 Excellent

3.4Name: Title: Length of Employment:

Monthly Pay: Bonus Pay: Salary: Hourly: Contract Labor:

General Duties:

Hours Required to Work Per Week: Typing W.P.M.: 10-Key By Touch:

Computer Experience (Training/Hours):

Seminars Attended:

Other Skills:

Doctor’s Personal Evaluation:Poor 1 2 3 4 5 6 7 8 9 10 Excellent

3.5Name: Title: Length of Employment:

Monthly Pay: Bonus Pay: Salary: Hourly: Contract Labor:

General Duties:

Hours Required to Work Per Week: Typing W.P.M.: 10-Key By Touch:

Computer Experience (Training/Hours):

Seminars Attended:

Other Skills:

Doctor’s Personal Evaluation:Poor 1 2 3 4 5 6 7 8 9 10 Excellent

3.6Name: Title: Length of Employment:

Monthly Pay: Bonus Pay: Salary: Hourly: Contract Labor:

General Duties:

Hours Required to Work Per Week: Typing W.P.M.: 10-Key By Touch:

Computer Experience (Training/Hours):

Seminars Attended:

Other Skills:

Doctor’s Personal Evaluation:Poor 1 2 3 4 5 6 7 8 9 10 Excellent

3.7Name: Title: Length of Employment:

Monthly Pay: Bonus Pay: Salary: Hourly: Contract Labor:

General Duties:

Hours Required to Work Per Week: Typing W.P.M.: 10-Key By Touch:

Computer Experience (Training/Hours):

Seminars Attended:

Other Skills:

Doctor’s Personal Evaluation:Poor 1 2 3 4 5 6 7 8 9 10 Excellent

3.8Name: Title: Length of Employment:

Monthly Pay: Bonus Pay: Salary: Hourly: Contract Labor:

General Duties:

Hours Required to Work Per Week: Typing W.P.M.: 10-Key By Touch:

Computer Experience (Training/Hours):

Seminars Attended:

Other Skills:

Doctor’s Personal Evaluation:Poor 1 2 3 4 5 6 7 8 9 10 Excellent

Note: If you have more than 8 employees, copy the page above and use that to list additional employees.

4.Your Clinic And Location Circle One

Poor Excellent

4.1Is your clinic easy to find?12345

4.2Is your clinic on a busy street?12345

4.3Is your clinic visible?12345

4.4Is your clinic accessible?12345

4.5Population of your city:

4.6Number of chiropractors in your city:

4.7Population of your drawing area (3-5 mile radius in urban areas, up to 50 miles in rural):

4.8Number of chiropractors in your drawing area:

4.9How well equipped is your clinic?12345

4.10Do you have enough space in your clinic?12345

4.11Is your clinic (your sign) well marked?12345

4.12Does your clinic have adequate parking?12345

4.13Do you rent or own your clinic?

4.14Is your clinic building a: “stand alone” strip center office building house/office combination other:

5.Your Schedule

All action takes time. Use the grid and abbreviations below to show your hours spent doing the following:

Practicing (Prac), Management (Man), Marketing (Mark), Exercising (Exer), and Leisure (Lei)

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30

6. Marketing

Internal

6.1What type of “in-house” marketing do you use in your clinic to stimulate new patient referrals? Please rate each on a 1 to 10 scale of effectiveness (1 being poor, 10 being excellent). (Example: A weekly New Patient Orientation Class where you offer a free examination to all family members. Rating 10)

Rating

External

6.2What type of outside marketing do you use to stimulate new patient referrals? Please rate each on a 1 to 10 scale of effectiveness (1 being poor, 10 being excellent). (Example: A direct mail campaign to your area offering a free examination. Rating 7)

Rating

7.Desires

I would like to see the following things happen in my practice, listed in order of importance:

8.Problems

I want help with the following major practice problems, listed in order of importance:

9.Winning The Game

How do you want Noel Lloyd and Five Star to assist you in reaching your desires and solving your problems? Instructions: Circle the appropriate number signifying where and how you would like assistance.

CoachingNot At AllVery Much

Leadership0 1 2 3 4 5 6 7 8 9 10

Encouragement0 1 2 3 4 5 6 7 8 9 10

Guidance0 1 2 3 4 5 6 7 8 9 10

Accountability0 1 2 3 4 5 6 7 8 9 10

Other0 1 2 3 4 5 6 7 8 9 10

Ideas

New Patients0 1 2 3 4 5 6 7 8 9 10

Staff Management0 1 2 3 4 5 6 7 8 9 10

Self Management0 1 2 3 4 5 6 7 8 9 10

Patient Management

Compliance0 1 2 3 4 5 6 7 8 9 10

Referrals0 1 2 3 4 5 6 7 8 9 10

Retention0 1 2 3 4 5 6 7 8 9 10

Other0 1 2 3 4 5 6 7 8 9 10

Business Management

Receivables0 1 2 3 4 5 6 7 8 9 10

Overhead0 1 2 3 4 5 6 7 8 9 10

Other0 1 2 3 4 5 6 7 8 9 10

Strategy

Marketing0 1 2 3 4 5 6 7 8 9 10

Office Team Building0 1 2 3 4 5 6 7 8 9 10

Retention0 1 2 3 4 5 6 7 8 9 10

Investing0 1 2 3 4 5 6 7 8 9 10

Other0 1 2 3 4 5 6 7 8 9 10

Materials

Your Own Training0 1 2 3 4 5 6 7 8 9 10

Staff Training0 1 2 3 4 5 6 7 8 9 10

Patient Training0 1 2 3 4 5 6 7 8 9 10

Marketing0 1 2 3 4 5 6 7 8 9 10

Other0 1 2 3 4 5 6 7 8 9 10

10.Operating Expenses(Note: A copy of last year’s Profit And Loss Statement and this year’s

Profit And Loss Statement may be substituted for this page.)

Date / Last 3 Months Average / Last 6 Months Average / Last 12 Months Average
Advertising
Automobile
Bank Charges
Meals And Entertainment
Computer
Depreciation
Dues And Subscriptions
Employee Benefits
Insurance
Interest
Legal And Accounting
Medical Supplies
Miscellaneous
Office
Payroll taxes
Resale Items
Printing And Publication
Professional Fees
Rent
Repairs And Maintenance
Salaries
Taxes-Other
Taxes-Excise
Telephone And Utilities
X-ray Expense
Business Loan (1)
Business Loan (2)
School Loan (1)
School Loan (2)
School Loan (3)
Other:
Other:
Other:
Other:
Total Operating Expenses:

10.1How often do you receive a report of business expenses by category to review?

10.2Do you have a computerized accounting system? If so, please list your system’s name.

10.3What outside specialists have you used in the past to analyze your business finances (i.e. other management consultants, CPA, etc.)?

10.4What is your current profit margin percentage (yearly net income/yearly sales)?

10.5Who pays the bills for your office?

How long have they been responsible for that duty?

Do they have check signing authority?

Do you receive weekly summaries of cash available and accounts payable?

10.6Who orders supplies for your office? Do you use a purchase order system?

10.7How much time do you personally devote to your finances (i.e. paying bills, analyzing financial statements, etc.)?

11.Statistics

11.1Please list your practice statistics including:

A.All the completed months of this year to date AND

B.The previous 36 months you have been in this practice (if that long).**

PLEASE DO NOT SUBSTITUTE COMPUTER GENERATED STATISTICS FOR THIS SHEET!

**Special Note: Copy this sheet for additional years.

Month/YearCollectionsServicesNew PatientsTotal Visits

1/
2/
3/
4/
5/
6/
7/
8/
9/
10/
11/
12/
Totals:

Month/YearCollectionsServicesNew PatientsTotal Visits

1/
2/
3/
4/
5/
6/
7/
8/
9/
10/
11/
12/
Totals:

Month/YearCollectionsServicesNew PatientsTotal Visits

1/
2/
3/
4/
5/
6/
7/
8/
9/
10/
11/
12/
Totals:

Month/YearCollectionsServicesNew PatientsTotal Visits

1/
2/
3/
4/
5/
6/
7/
8/
9/
10/
11/
12/
Totals: