Survey on Health for the Whole Family Program

We are trying to measure the success of this program so please take a few minutes to give us your feedback. You can complete the form and fax it back to Michael Campea at 312.202.8343 or e-mail your responses to mcampea@aoa-net.org. Thank you!

1. How have you used these articles?

____ Printed in my local newspaper.

____ Printed in my hospital newsletter.

____ Reading material for patients in my waiting room.

____ Other, please specify in the space below.

If an article has appeared in a publication, please provide the publication's name, and the topic of the article. Also, please fax a copy of the article to 312.202.8343.

2. Do you prefer receiving the articles via…

____ Fax* ____Regular mail ____ E-mail*

*If you chose fax or e-mail, please provide us with your fax number or e-mail address below.

Fax: ________________________________

E-mail: ________________________________

3. Do you have any suggestions for future topics?

4. Do you have any other comments on Health for the Whole Family that you would like to share? Please use the space below.

Thank you for taking the time to respond!