ExecTech Client - Personal Questionnaire
Ideally complete the form in one sitting. If you are not able to do so, you can click "Save Progress" at the bottom of the form, then choose "Skip Create an Account", then enter your email address to get your draft form sent to you for finishing later on.
Name
*
First Name
Last Name
Doctor Type (MD, DDS, DO, etc)
*
Practice Name
*
Speciality
Email
*
example@example.com
Cell Phone
*
Please enter a valid phone number.
1. Where are you from?
2. What schools did you attend?
3. What degrees have you earned?
4. Where are you licensed to practice?
5. How long have you been licensed?
6. What specialities have you mastered?
7. Why did you select this career?
8. What do like most about your career?
9. What do you like least about your career?
10. If you could start over, what, if anything, would you have done differently regarding your career choices?
11. Where did you first practice? What problems did you encounter? Why did you leave?
12. Where did you practice next? What problems did you encounter? Why did you leave?
13. Where else have you practiced? What problems did you encounter? Why did you leave?
14. What are your major accomplishments to date?
15. Please describe your current physical condition:
16. Do you have any reading or language difficulties?
17. What is your spouse's name?
18. What roles does your spouse have in the practice?
19. Are you having any marital or family difficulties that could affect the practice?
20. Besides money, what personal benefits do you hope to achieve from your practice?
21. What are your most positive or valuable personality traits?
22. What about yourself have you successfully changed or improved over the past few years?
23. What programs, activities or counseling have you experienced that have helped you on a personal level?
24. What programs, activities or counseling have you experienced that did not help you?
25. How often do you feel stressed?
26. What are the causes of this stress?
27. Have you had any accidents recently?
28. Have you been ill recently?
29. Have you recently made any major mistakes?
30. How do you feel about being helped?
31. What aspect about yourself, if changed, would make you happier?
32. What, if any, difficulties do you have in following directions?
33. How do you feel about being supervised by others?
34. Is there anyone opposed to you or anything you are doing? If so, please describe:
35. Is there anyone who is harming you or the practice (whether they intend to or not)?
36. What, if any, elements outside your practice are distracting to you?
37. What aspects of your practice make you feel apathetic?
38. What aspects of your practice make you feel sad?
39. What aspects of your practice make you feel afraid?
40. What aspects of your practice make you feel terrified?
41. What aspects of your practice make you feel worried?
42. What aspects of your practice make you feel enraged?
43. What aspects of your practice make you feel antagonized?
44. What aspects of your practice make you feel bored?
45. What aspects of your practice make you feel cheerful?
46. What aspects of your practice make you feel enthusiastic?
47. What aspects of your practice make you feel serene?
48. What is difficult for you to face or do regarding marketing?
49. What is difficult for you to face or do regarding patients?
50. What is difficult for you to face or do regarding your staff?
51. What is difficult for you to face or do regarding collections?
52. What is difficult for you to face or do regarding finances?
53. What is difficult for you to face or do regarding practice management?
54. When would you like to take your next vacation?
55. What are your personal goals (practice goals are asked later) for the next year?
56. What are your personal goals for the next five years?
57. What are your personal goals for the next 10 years?
58. What are your personal goals for the next 20+ years?
59. What are your biggest concerns in reaching these goals?
60. What are your family goals for the next year?
61. What are your family goals for the next five years?
62. What are your family goals for the next 10 years?
63. What are your family goals for the next 20+ years?
64. What are your biggest concerns in reaching these goals?
65. Any other personal information you would like to add?
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