Please answer all questions below to enter to win a continuing education scholarship for the conference of your choice. Incomplete forms are ineligible for the drawing.  Drawings are held at the end of every month.

Monthly Winner

GENERAL INFORMATION

First Name:

Last Name:

Degree:

Address (Line 1):

Address (Line 2):

City:

State:

ZIP Code:

Telephone:

Fax:

Email Address:

Re-enter Email Address:

ABOUT YOUR PRACTICE

Practice/Specialty:

Practice Setting:


If other, please specify:

Is your practice:

How long have you been in practice?:

ABOUT CONTINUING MEDICAL EDUCATION

Have you attended a previous Symposia Medicus program?

What THREE factors are most important to you when deciding on a CME program?:
(Please check only three)

CME Sponsor
     (medical school, specialty company, hospital, etc.)
Faculty
Content
Cost of program
Location
     (resort area, entertainment, etc.)
Need for CME credit
Close to home
Far from home

Where are your favorite three destinations in the United States for CME?:



Where are your favorite three foreign destinations for CME?:



How interested would you be in attending a 2-3 day CME rafting trip down the American River, with a mixture of lecture topics?

 How interested would you be in attending a CME conference on a cruise ship?

 If you were to attend a CME conference on a cruise, what destination would you prefer?

 If you were to attend a CME conference on a cruise, what other destinations would you suggest?



 Please tell us the top three months you would prefer to attend a CME cruise:

1:
2:
3:

Please suggest subject areas in which you would like to have more information via CME (e.g., HTR, ADHD, Hypertension, Fetal Monitoring, etc.) and the format you prefer from the dropdown list on the right:

Please list in descending order of importance, with the most important subject area first, and the least important last.

1.
2.
3.
4.
5.

Are there non-clinical educational needs that you would like more information about (e.g., practice economics, patient social problems, malpractice, bioethics issues, etc.)?

Please list in descending order of importance, with the most important subject area first, and the least important last.

1.
2.
3.
4.
5.

Given the above ten subject areas, what are the top three you would like to see in your next CME conference?

What are the top three avocational topics you would attend at one of our educational programs?
(i.e. Medical Spanish, Regional Cooking)

Would you take advantage of the opportunity to email faculty with questions or issues you would like to have addressed in an upcoming course?:

Please contact me about future CME programs via: