Patient Demographic Data Sheet Template
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2Demographic Data Sheet
Patient Information
First: ___________________ MI: ____ Last: _________________ Gender: Male/Female/Transgender
Date of Birth (MM/DD/YYYY):____ /____ /_____ Patient Social Security Number: ____ - ___ - _____
Home Phone: (____) ____ - _____ Cell Phone: (____) ____ - _____ Work Phone: (____) ____ - _____
Email Address: _________________________________________________
Primary Care Provider (PCP): ______________________________ Date of Last Visit: ___ / ___ / ____
Preferred Patient Language: ______________________________ Interpreter Needed: YES or NO
Housing Situation (Check One):
At risk for homelessness
Race:
Currently not homeless, was in last 12
Alaskan Native
months
Homeless, unknown shelter
American Indian
Living in shelter
Asian
Living with others
African American/Black
Not homeless
Native Hawaiian
Street, Camp, Bridge
Unknown
Transitional housing
Pacific Islander
Migrant/Seasonal:
Prefer Not to Answer
Caucasian/White
Migrant
Neither
Income:
Seasonal
Number of people who live in your home: ____
Ethnicity (Check One):
Hispanic
Total Household Income:
Non-Hispanic
____________ Monthly or Annual
Not Collected/Unknown
Prefer Not to Answer
Marital Status: Married/Divorced/Single
Are you a Veteran? Yes or No
Are you legally disabled? Yes or No
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Parent category: Medical