Practice Analysis Questionnaire

(Download the fillable PDF version if you prefer. To avoid losing your work, we recommend typing your answers in a separate document first and then pasting them into the form.)
Employee Census (Including: Self, All Employees, Independent Contractors)
NamePositionSalary
Description of Office Space (Current and Projected)
Patient Demographics (Number Of)
Age GroupCount
0 – 12
13 – 18
19 – 40
41 – 60
60+
Total
Socioeconomic Data (Subjective Percentage Estimate)
GroupPercentage
Poor
Lower Middle Class
Upper Middle Class
Wealthy
Total %
Ideally this should add up to 100%.
Financial Estimates (P&L for Previous 3 Years for Practice Only)
YearGross IncomeOverheadNet Profit (auto-calculated)
Practice Goals and Expectations
Leadership
Branding
Business Systems
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