Self Assessment Questionnaire Name* Best phone number to reach you* Practice location* Practice hoursAMPMMondayTuesdayWednesdayThursdayFridaySaturdaySunday How many weeks of personal vacation taken annually? How many ops for restorative? How many ops for hygiene? How long have you been practicing? Do you own the practice? SelectYN -If yes, how long? -If yes, do you feel like a ‘Business Owner’ or ‘Business Operator? Does the practice have a clear VISION Statement? SelectYN - If yes- please share Do you have a clear plan to achieve your Vision? SelectYN Rate the ‘Health’ of your Team Culture Rate your External Marketing Rate your Internal Marketing How many ‘Active patients’? (Patient has been in for an appointment within the past 16 months) How many New Patients per month on average? How many ‘days of hygiene’ (8hr shift) per week? List all team members (first name) and position When did you last ‘audit’ ALL of the systems/policies in your practice? Is your practice assignment? SelectYN Do you conduct daily ‘morning huddles’ that are productive and fun? SelectYN Do you conduct monthly ‘team meetings’ that are productive and fun? SelectYNHas your team been properly trained with ‘quality communication skills... -To increase ‘Case Acceptance’ ? SelectYN -To increase ‘Efficient and Effective Scheduling’? SelectYN -To handle ‘objections? SelectYN -To best answer the phone/questions? SelectYN - To best present ‘report of findings’ at a recall appointment? Average Monthly practice production? -Doctor production? -Hygiene production? -Average monthly A/R? Is your team able to ‘bonus’ on a monthly basis? SelectYN List 3 Areas of the practice that you feel work really well List 3 Areas of the practice that you feel need attention Have you ever worked with a dental coach or consultant? SelectYN Please list anything else that you feel I would benefit from knowingSubmitReset
