Patient Demographics Questionnaire Template Page 3

PATIENT DEMOGRAPHICS QUESTIONNAIRE—Self-Administered

We want to make sure that all of our patients get the best care possible. We would like you to tell us

your racial and ethnic background so that we can review the best treatment that our patients can

receive and make sure that everyone of every background gets the highest quality of care. It is also

important that we know your preferred spoken language so that you and your health care team can

have good communication.

We will keep this information private and will update it in your medical record. Your answers are

confidential.

You need not answer any question you prefer not to answer.

You have been provided a list of Frequently Asked Questions to help answer any questions that you

may have about this form. Our registration staff members are happy to answer your questions.

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Parent category: Medical