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Patient Questionnaire: Help Us Understand Your Health Better

Please fill out the form below to assist us in providing the best care and enrolling you in suitable clinical projects!

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Patient Demographics and

History Information Form

Please fill out the following form.

Date of birth
Month
Day
Year
Patient’s sex
Male
Female
Other
Language(s) spoken by patient?
English
Spanish
Other
What category best describes your race (one or more may be marked)
American Indian or Alaska Native
Black or African American
White
I choose not to answer
Asian
Other
Please specify your ethnicity
Hispanic or Latino
Not Hispanic or Latino

Emergency Contact Information

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