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?
Yes No
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
Male
Age Group?
<Select One>
Under 21
21-30
31-40
41-50
51-60
61-70
Over 70
Marital Status?
<Select One>
Married
Widowed
Divorced
Single
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?