21 Keys Questionnaire for new doctors Right Start Questionnaire for new doctors Step 1 of 7 - Personal Background 14% About YouTo get started, we're going to ask some personal information about you. You can track your progress with the bar at the top of this form, and can save and continue at any point. Let's get going!Name First Last Date of Birth MM DD YYYY Place of BirthAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email Home PhoneCell PhoneFax NumberOther PhoneFamily InformationAre you married?YesNoSpouse InformationSpouse's Name First Last Spouse's OccupationChildren InformationDo you have children?YesNoChildren's InformationPlease list your children's name(s) and age(s):Additional Family InformationWhat is your home town and state?Name of parents (or a relative with a fixed address)Parent's Phone NumberGreat!Next, we're going to ask a few questions about your education. Save and Continue Later Education and LicensingTell us a little more about your education.Name of Chiropractic CollegeMonth and year of graduationWhat states are you licensed in?Moving onThe next section focuses on your post-college experiences. Save and Continue Later Chiropractic BackgroundThis section examines some of your post-college experience and future goals.Who referred you to AMC?What National Boards have you passed?Tell us about any professional experience you have.What seminars have you taken?Why are you applying with AMC Right Start?List names of clubs, fraternities, or sororities of which you are a member.What chiropractic techniques are you planning to use?Do you plan to use qualified therapies?YesNoWhat therapies do you plan to use?What are your sports and activity interests and in which ones do you and your spouse (if applicable) participate?Moving OnLet's next look at your ideal practice size and location. Save and Continue Later Facilities and LocationsTell us a little more about your ideal practice.What is population of your ideal town?What state do you intend to practice in?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPlease list any equipment you already own.What is your ideal market size?You're doing great!Next, we're going to ask about your finances. This information is kept strictly confidential. Save and Continue Later FinancialAll information is kept strictly private and confidential.Do you have any financial backing?YesNoWhat type and how much?Do you have any working capital?YesNoWhat type and how much?What is your approximate credit score?All done with financials!The next section helps us understand you as a person. Save and Continue Later Personal BackgroundThis section helps us understand your personality, motivations, and goals. Remember, there are no right or wrong answers here.There are no right or wrong answers to the following questions.Please be objective. We want to know how to best serve you.Are you a do-it-yourselfer?YesNoPlease explain:Do you need to figure things out for yourself, or do you seek instruction to avoid mistakes when faced with a new project?Figure it out myselfSeek instructionAre you willing to follow a system that is moral, legal, and ethical, without picking and choosing only some components while ignoring others?YesNoHow do you know you will be a good chiropractor?Where would you like to open your practice and why?Will you risk your comfort zone to grow beyond where you could on your own?YesNoAlmost done!You're on the home stretch! Just one more section to go. We're going to follow up a little on your personality and then you're done. Save and Continue Later SummaryAs before, there are no right or wrong answers to this section. These questions help us determine the best ways to help you reach your goals.Do you tend to be more competitive or cooperative?CompetitiveCooperativeCompetitive people have what is called a Production Drive. They are inclined to be task-orientated. Cooperative people, on the other hand, have what is termed a Connection Drive—in other words, they tend to be people-oriented or people-centric.Do you prefer constancy or change?ConstancyChangePeople who prefer constancy have what is referred to as a Stability Need—a desire for consistency, order, and routine. In contrast, people who prefer change have what is called a Variety Need; they are stimulated by new experiences and energized by change.Which would make you feel more valued at work: sincere appreciation without financial bonus, or a bonus without appreciation?AppreciationBonusIf you would rather have appreciation, you possess what is called an Internal Award system—one characterized by private recognition and contribution. If you would rather have the monetary bonus, you have what is called an External Award system—one characterized by public recognition and opportunity for advancement.Select which thought pattern best describes you.Choose which direction you tend toward.I tend to:Avoid Risk+++Neutral+++Manage RiskI tend to:Love to be comfortable+++Neutral+++Be comfortable being uncomfortableI tend to:Operate out of fear and scarcity+++Neutral+++Operate out of love and abundanceI tend to:Operate out of fear and scarcity+++Neutral+++Operate out of love and abundanceI tend to:See myself as a victim+++Neutral+++See myself as responsibleI tend to:Be problem oriented+++Neutral+++Be solution orientedI tend to:Handle things on my own+++Neutral+++Be eager to learn from othersWhat additional assistance would you like from AMC Right Start?If accepted into the Right Start Program, are you willing to: Learn and be coached Send in monthly statistics Open your office for an inspection by AMC Attend AMC Boot Camps Visit AMC-approved training centers Commit to running a practice that is moral, legal, and ethical Do whatever it takes to achieve YOUR goal Check all that apply.Select your motivation level1 Somewhat motivated2345 Highly motivatedWould you be interested in an Advanced Associate position in a successful AMC office?YesNoFantastic!All that's left is to hit the submit button below. We know that was a lot of work, but it will be worth it to start the journey to accomplishing your goals!CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.