Dr. Charles Ward Innate Legacy
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"Practice Evaluation Worksheet"
This process will be followed by a free 10 call With "Coach Charles E. Ward"
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Doctor's Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Work Phone
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Fax Number
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Cell Number
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Spouse
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Children
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place comma between names
How did you hear about us?
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Years In Practice
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1) Is your practice at its maximum new and weekly visit capacity?
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Yes
No
2) Are you growing your practice by at least 5-10% or more per year?
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Yes
No
3) Do you currently have a 12 month marketing plan?
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Yes
No
4) Are you monitoring your return on investment on your marketing?
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Yes
No
5) Is your practice currently profitable?
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Yes
No
6) Do you currently meet with your team weekly?
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Yes
No
7) Do you have a weekly training program in place for your team?
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Yes
No
8) Are you witnessing an increase in your patient weekly patient visits?
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Yes
No
9) Do you currently use payment plans?
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Yes
No
10) Does your marketing include outside talks, referral programs, website?
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Yes
No
11) Do you currently re-invest more than 5% of your gross in personal and practice development?
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Yes
No
12) Do you implement progress/re-evaluation procedures to demonstrate change in patient’s overall well being?
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Yes
No
13) Are you currently performing a spinal care class to your new patients?
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Yes
No
14) Do you have family plans and wellness plans in place for your patients?
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Yes
No
15) Are you utilizing training, policies, systems, procedures, and leadership skills in the practice to decrease your stress, increase team morale, create an efficient, high energy, mission based office having more fun?
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Yes
No
16) Are you currently performing daily rituals of exercise, affirmations and nutrition to create an abundance of energy and mental focus?
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Yes
No
17) Have you created a 5, 10, 25 year dream and goal list to be, do, have more in life?
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Yes
No
18) Do you have a consistent patient education system in place?
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Yes
No
19) Are your patient’s spouses attending the Report of Findings?
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Yes
No
20) Are your CA’s enthusiastic and excited about serving more people?
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Yes
No
Please provide the following information to help us better serve you
1. Do you currently have a coach to help you create the practice of your dreams and an extraordinary quality of life?
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Yes
No
2. If you were to easily add 10-20 more new patients in a month, would you make an emotional commitment to make the changes needed to achieve these growth targets?
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Yes
No
3. If I continue with my practice in the direction it’s going, I’ll be financially independent in 3-5 years.
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Yes
No
4. Is a lack of new patients, income, life balance affecting your joy in practice; ability to do and have more in life, plan for retirement, provide the best for your children?
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Yes
No
How can we best help you as a coach?
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What would you like to work weekly?
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Would you like more information regarding Innate Legacy emailed to you?
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Yes
No
6. What is the number of hours you currently work weekly?
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7. How many new patients do you see on an average per month?
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8. What is the number of weeks vacation you’ll take this year?
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9. What is the number of weeks vacation you’d like to take each year?
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10. How much would you like to increase your net practice income in the next 12 months?
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11. What Chiropractic technique(s) do you use in your practice?
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