PATIENT DEMOGRAPHIC INFORMATION

DUPAGE PEDIATRICS, LTD

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Patient Name

Date of Birth:

Names of Siblings This Information Applies To:

Email Address

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PLEASE CHOOSE AN ANSWER FOR EACH OF THE 3 SECTIONS BELOW:

Ethnicity

Hispanic or Latin

Non Hispanic or Latin

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RACE

White

American Indian /Alaska Native

Native Hawaiian and Other Pacific Islander

Black or African American

Black

Asian

Other Race

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PREFERRED LANGUAGE:

English

Arabic

Polish

Spanish

Chinese

Other Language

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If Other, Please Specify

If Other, Please specify language

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