Survey

This survey is anonymous and all answers will be kept in the strictest of confidence.

Which doctor did you see?

Dr. Maurer	Dr. Vincent	Dr. Sun

When where you first seen at WFASM?

Winter	Spring	Summer	Fall	Year:

Age range

<5	6-12	13-18	19-25	26-35	36-45	46-55	56-65	66-75	>75

Gender:

	Male
	Female

In which activities do you (or your child if a parent is filling out the survey) participate?
Click on only your primary activity

How would you describe your level of participation?

In which other activities do you participate? (Check all that apply)

How would you describe your level of participation?

Referral

I was referred by:

	Primary care physician
	Sports medicine physician
	Pediatric primary care sports medicine physician
	Pediatrician
	Orthopedist
	Chiropractor
	Physical therapist
	Trainer
	Friend
	Family

Other medical professional
Other

I would refer friends/family.

	Yes
	No

I have referred friends/family.

	Yes
	No

Front office Staff

Friendliness/Courtesy of Reception
1: Very Poor
10: Exceeds Expectations

	1	2	3	4	5	6	7	8	9	10
The front office staff was/is friendly
The front office staff was/is courteous
The front office staff was/is helpful