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* 1. How were you referred to this survey?

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* 2. Current City/Town of residence

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* 3. How many children are in your family (21 years old and younger)?

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* 4. How many adult (22 years old and up) family members play sports in your household?

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* 5. In which of the following sports do adults in your household participate in? (Please choose all that apply)

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* 6. How many children in your household play sports?

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* 7. In which of the following sports do children in your household participate in? (Please choose all that apply)

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* 8. Would you be interested in a course that teaches you and/or your family members how to reduce the risk of sustaining specific injuries, such as knee injuries that require surgery to repair?

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* 9. Would you be interested in having your child's pre-participation physical examination performed by a certified sports medicine physician and include:
Full pre-participation physical as recommended by the Academy of Pediatrics
A full heart examination including an EKG
Full concussion baseline testing including computerized brain function and balance assessments
Recommended eye examination including pupil measurements

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