Patient Registration Demographic Form Patient Demographic Sheet Date: * Patient Name: * Last name, First Name, Middle Name Gender: * Male Female Transgender Date of Birth: * Address: * Address: Address: Address: City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Home Phone: Cell Phone: * Email Address: * Emergency Contact Name: * Emergency Contact Relation to Patient: * Emergency Contact Cell Phone: * Do you speak English? * Yes No Do you speak a language other than English at home? * Yes, I speak:Yes, I speak: No Would you like an interpreter if one could be made available? * Yes, I would like an interpreter that speaks: Yes, I would like an interpreter that speaks: No How well do you speak English? * Very well Well Not well Not at all What language do you feel most comfortable speaking with your doctor or nurse? * Race – Check all that Apply: * White/Caucasion Black/African American American Indian Alaska Native Asian Asian Indian European Filipino Japanese Korean Native Hawaiian Pacific Islander OtherOther Prefer not to answer Ethnicity – Check all that Apply: * Central American Cuban Dominican Hispanic/Latino Mexican Not Hispanic/Latino Puerto Rican South American Spaniard OtherOther Prefer not to answer Status: * Married Single Divorced Separated Remarried Widowed Minor Child Partner Current Housing: * Homeless Shelter Transitional Apartment House/Mobile Home Street Doubling Up Housing Assistance How did you hear about us? * Appleton Alliance Church Business, enter in referred Community Care at AAC ER Provider, add referred by Facebook Family or Friend, add referred by Hospital – Ascension Hospital – Aurora Hosptial – ThedaCare OtherOther Radio, TV, Newspaper Sign Thompson Center on Lourdes (TCOL) UMOS Website I was referred by: Referred byReferred by How did you get here today? * Drove Taxi Bike Bus Walk Friend/Family Make The Ride Happen Give Help Get Help Dial-A-Ride OtherOther Religion: Atheist Baptist Buddhist Catholic Christian Christian Missionary Alliance Hindu Jehovah’s Jewish Lutheran Methodist Mormon Muslim/Islam Native American Non-Denominational None OtherOther WICCA Insurance: * Private Insurance Exchange Medicaid/Badger Care Medicare VA Insurance No Insurance Employment Status (Choose the best description for your situation) * Full-time Part-Time Self-Employed Unemployed Seasonal Worker Temporary Worker Retired Disabled Student Military Have you lived in a shelter, on the streets, or been homeless in the last year? * Yes No Preferred Pharmacy & Location: * reCAPTCHA Submit If you are human, leave this field blank.