*Name


Age


*Email


Address


Address 2


City


State


Zip

In what sports do you and/or your family participate?

If Other, what?

What is limiting your athletic or active lifestyle goals?

Time
Injury
‘How To’ Knowledge
Strength
Lungs
Heart
Illness
Equipment
Lack of Commitment

Do you currently have an injury or illness?
Yes No

Are you currently rehabilitating an injury?
Yes No

If yes:
Orthopedic
Strain/Sprain
Cardiopulmonary

Site Review

How did you learn about the Texas Sports Medicine Center Web site?

On a scale of 1 to 5 (1 being poor and 5 being excellent), how would you rate the following:

Navigation
1 2 3 4 5

Download Time
1 2 3 4 5

Information Available
1 2 3 4 5

What additions would you like to see on this site in the future?

Would you like a reply?
Yes No

Further comments or questions?