Patient Demographic Form Page 2

Pre-printed SID number

RED

6. Indicate your highest level of education (check one):

☐

Less than a high school diploma

☐

High school graduate (including equivalency, GED, etc.)

☐

Some college or Associate Degree

☐

Bachelor’s Degree

☐

Graduate Degree (including Master’s, Doctoral, etc.)

☐

Decline to answer

7. Zip code where you live: |___|___|___|___|___|

Thank you for completing the form!

MDH-Patient-Demographic-Form-2015-02-12-V2.0.docx

Page 2 of 2

Owner: Westat/Lisa Bowser

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Parent category: Medical