Patient Demographics Questionnaire Template (Page 4 of 4) in pdf

Patient Demographics Questionnaire Template Page 4

PATIENT DEMOGRAPHICS QUESTIONNAIRE—Self-Administered

1. Are you of Hispanic, Latino, or Spanish origin? (Mark ONE box.)

Yes______________________________(specify (e.g. Mexican, Puerto Rican, Cuban, etc.))

No, not Hispanic, Latino, or Spanish origin

2. What is your race? (Mark one or more boxes.)

White/Caucasian

Asian

Black/African American

Native Hawaiian or Other Pacific Islander

American Indian/Alaska Native

Some other race: _____________________ (specify)

3. IF MORE THAN ONE RACE (Question #2) IS CHECKED: Do you identify with any one race

in particular?

Yes _________________________ (specify)

4. What language do you feel most comfortable using when speaking to a doctor or nurse?

English

Spanish

Another language: ___________________________________ (specify)

5. What language do you prefer receiving written medical information?

English

Spanish

Another language: ___________________________________ (specify)

6. How well do you speak English?

Very well

Patient does not understand question

Well

Patient is unconscious/unavailable to answer

Not well

Not at all

7. How well do you understand English?