PHYSICIAN QUESTIONNAIRE

Physician Name Specialty/Sub-specialty Home Phone Cell Phone Best Contact# Email Address Preferred hours to call 1. What are your geographic preferences? (Please provide us any cities you would really like to work in so we can contact all those practices)? 2. Are you interested in Locums or Permanent opportunities? 3. Will you consider locums while looking for the right permanent job? 4. What size(s) of community are you seeking? 5. How soon can you relocate? 6. When do you plan on making a decision? 7. Why are you leaving your present position? 8. Where is your hometown and do you have a desire to return? 9. What type of practice are you seeking? List any or all, e.g., MSG, SSG, Solo, employed, academic, etc.? 10.What states are you licensed or where have you applied for a license(s)? 11.Do you have any inactive license(s)? 12.What are your minimum salary

requirements? What type of pay compensation are you currently on? 13.What is your desired call schedule? 14.What is your spouses name? 15.Where is your spouses hometown? 16.Where are your spouses family ties and would you like to relocate near any of his/her family? 17.What is your spouses occupation? 18.Do you have children? If so, what type of schools are you looking for or any special needs? 19.Do you have any special family needs? 20.Are you a U.S. Citizen? If not, are you on a visa or green card? 21.Are you Board Certified? If not, what are you Board Eligible in and when do you plan on taking the Board? 22.What dates do you have available for interview? 23.Where has your CV been presented or where have you interviewed? 24.Of those interviews, was an offer made? If so, why did you not accept? 25.Do you have any record of past or present malpractice history? If so, please explain. 26.Has your license ever been limited or revoked? 27.Have you ever been refused

membership on a hospital staff or had your privileges revoked? 28.Have you ever been treated for alcohol or drug abuse? 29.Have you ever been convicted of a felony? 30.Any special procedures you like/dislike?

31.Languages spoken? 32.Any information that will give you a competitive edge over other candidates? 33.Any special interests (i.e., hunting, fishing, arts, sports, etc.)? 34.Do you have a non-compete clause in your contract? If so, what are the parameters? 35.Training: - Medical Degree: - Year: - Residency: - Fellowship: - Year finished training: