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 AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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: * Alaska Native or American Indian Asian Asian Indian Black/African American Native Hawaiian or Pacific Islander White/Caucasion OtherOther Prefer not to answer Ethnicity – Check all that Apply: * Not of Hispanic, Latino, or Spanish origin Cuban Puerto Rican Mexican, Mexican American, Chicano Other Hipanic, Latino or Spanish OriginOther Hipanic, Latino or Spanish Origin 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 Δ