Race And Ethnicity Questionaire Template
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1RACE AND ETHNICITY QUESTIONAIRE
Please provide us with information on you and family members that are patients here. We ask for this information related to diseases more
prevalent among certain ethnicities or races.
Please list name and birthdate for any family member seen here along with race and ethnicity.
NAME:
D.O.B:
/
/
RACE (Circle one)
White
Black
Asian
Indian/Alask
Pac Isle
Hsp-
Hsp-
Other/Mult
Hsp-White
Black
Hsp-Asian
Ind/Alask
Hsp-Pac
Hsp-Other-
Isl
Mult
Ethnicity (Circle
one)
Hispanic
Non-Hispanic
NAME:
D.O.B:
/
/
RACE (Circle one)
White
Black
Asian
Indian/Alask
Pac Isle
Hsp-
Hsp-
Other/Mult
Hsp-White
Black
Hsp-Asian
Ind/Alask
Hsp-Pac
Hsp-Other-
Isl
Mult
Ethnicity (Circle
one)
Hispanic
Non-Hispanic
NAME:
D.O.B:
/
/
RACE (Circle one)
White
Black
Asian
Indian/Alask
Pac Isle
Hsp-
Hsp-
Other/Mult
Hsp-White
Black
Hsp-Asian
Ind/Alask
Hsp-Pac
Hsp-Other-
Isl
Mult
Ethnicity (Circle
one)
Hispanic
Non-Hispanic
G:shared doc mw/mw patient forms/raceandethnicityquestionaire
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