Patient Demographic Form
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2Pre-printed SID number
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SENSITIVE TEETH STUDY
Patient Demographic Form
Today’s Date:
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Questions About You
1. Your gender:
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Male
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Female
2. Your Date of Birth: |___|___|/|___|___| /|___|___||___|___|
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3. Your ethnicity (check one):
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Hispanic or Latino
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Not Hispanic or Latino
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I don’t know
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Decline to answer
4. Your race (check all that apply):
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American Indian or Alaska Native
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Asian
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Black or African-American
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Native Hawaiian or Other Pacific Islander
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White
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I don’t know
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Decline to answer
5. Select the type(s) of dental insurance that covers your dental care (check all that apply):
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Private insurance (e.g., commercial, HMO, etc.)
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Public/Government insurance (e.g., Medicaid, military or veterans, etc.)
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No insurance coverage
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Other (please specify): _____________________________
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I don’t know
MDH-Patient-Demographic-Form-2015-02-12-V2.0.docx
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Owner: Westat/Lisa Bowser
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Parent category: Medical