Plymouth Family Physicians

RACE AND ETHNICITY QUESTIONAIRE

Please provide us with information on yourself and any family members that are patients here. We are asking for this information due to the fact that some diseases are more prevalent among certain ethnicities or races. If we know your ethnicity and race we are better able to create a treatment plan that is geared toward your specific situation.

Below please list your name and birthdate and anyone else in your family that is seen here along with RACE:(White, Black, Asian, Indian/Alask, Pac Isle, Other/Mult, Hsp-White, Hsp-Black, Hsp-Asian, Hsp-Ind/Alas, Hsp-Pac Isl, Hsp-Other/Mult), and ETHNICITY: (Non-Hispanic, Hispanic).

Name: (required)
E-mail Address
Birth Date


Race
White
Black
Asian
Indian/Alask
Pac Isle
Other/Mult
Hsp-White
Hsp-Other/Mult
Hsp-Asian
Hsp-Ind/Alas
Hsp-Pac Isl

Ethnicity
Hispanic
Non-Hispanic

Other family members with the same race and ethnicity
Please enter Name and Birthdate

Second Person's Name:
Second Person's Birth Date


Second Person's Race
White
Black
Asian
Indian/Alask
Pac Isle
Other/Mult
Hsp-White
Hsp-Other/Mult
Hsp-Asian
Hsp-Ind/Alas
Hsp-Pac Isl

Second Person's Ethnicity
Hispanic
Non-Hispanic

Second Person - Other family members with the same race and ethnicity
Please enter Name and Birthdate

Third Person's Name:
Third Person's Birth Date


Third Person's Race
White
Black
Asian
Indian/Alask
Pac Isle
Other/Mult
Hsp-White
Hsp-Other/Mult
Hsp-Asian
Hsp-Ind/Alas
Hsp-Pac Isl

Third Person's Ethnicity
Hispanic
Non-Hispanic

Third Person - Other family members with the same race and ethnicity
Please enter Name and Birthdate

Race-the color of ones skin, your appearance. (i.e. black, white, etc.)
Ethnicity-your actual biological background (i.e. African American, Brazillian, Irish, etc.)

I understand that the information on this page will be sent to Plymouth Family Physicians, S.C. and that this submission is not secure. If you are concerned, don't click the Submit button and PRINT THIS FORM or SAVE IT AS A FILE after completing it. You can then mail it or drop it off at the office. If you choose to complete this form at the office, please arrive at least 30 minutes before your appointment to complete all paperwork.