What illness or injury brought you to SickKid.net? (You may select multiple illnesses or injuries by holding down the Ctrl key while selecting with the left mouse button.)

Fever Stomach Problem Rash Poison Cold/Flu Body Pain Cough Head Trauma Diarrhea Other

What was the nature of your visit with us?

Crisis Information Services Referral Resources Career Other

What is your source for Healthcare Information?

Web Library Yellow Pages Print ads Radio-TV ad Direct Mail Other

What is your level of familiarity of pediatric services in your immediate area?

<Select One> None Little Somewhat familiar Very familiar

How many hours per week do you spend on the Internet?

0 - 5 hours
6 - 10 hours
11 - 15 hours
16 - 20 hours
more than 20 hours

Would you be interested in participating in weekly chats?

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What is your zip code?

How many years in this area?

<Select One> Less than 1 year 1-2 years 2-4 years 4-6 years 6 or more years

Your gender?

Female
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Age Group?

<Select One> Under 21 21-30 31-40 41-50 51-60 61-70 Over 70

Marital Status?

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Number of children?

Ages of Children? (Use comma to separate)

Annual Household Income?

<Select One> Under $20,000 20,000 - 40,000 40,000 - 60,000 60,000 - 80,000 80,000 - 100,000 100,000 - 120,000 120,000 - 140,000 140,000 - 160,000 Over $ 160,000

Your EMail Address?