Patient Demographic Information
Lamoille-500.34D
Patient Name:
Date of Birth:
-
Month
-
Day
Year
DEMOGRAPHIC INFORMATION
As a Federally Qualified Health Center we are required to collect the following information:
Primary Language Spoken:
English
Spanish
Other
Will you Need Interpreter Services?
Yes
No
Race
Asian
Black / African American
Native Hawaiian
Other Pacific Islander
White
American Indian/Alaskan Native
Other/Refused to Report
Ethnicity:
Hispanic
Non-Hispanic or Latino
Refused to Report
Are you Homeless?
Yes
No
Select conditions below:
Homeless Shelter
Transitional
Doubling up
Street
Other
Are you a Migrant Worker?
Yes
No
Are you a Seasonal Worker?
Yes
No
Are you a United States Veteran?
Yes
No
Household Size (Include yourself):
Please Select
1
2
3
4
5
6
7
8
Other
I Decline to Answer This
Yearly Household Income (please check one):
0-12,880
12,880.01-17,130.40
17,130.41-21,380.80
21,380.81-25,760
Other
Yearly Household Income (please check one):
0-17,420
17,420.01-23,168.60
23.168.61-28,917.20
28,917.21-34.840
Other
Yearly Household Income (please check one):
0-21,960
21,960.01-29,206.80
29,206.81-36,453.60
36,453.61-43,920
Other
Yearly Household Income (please check one):
0-26,500
26,500.01-34,245.00
34,245.01-43,990.00
43,990.01-53,000
Other
Yearly Household Income (please check one):
0-31,040
31,040.01-41,283.20
41,283.21-51,526.40
51,526.41-62,080
Other
Yearly Household Income (please check one):
0-35,580
35,580.01-47,321.40
47,321.41-59,062.80
59,062.81-71,160
Other
Yearly Household Income (please check one):
0-40,120
40,120.01-53,359.60
53,359.61-66,599.20
66,599.21-80,240
Other
Yearly Household Income (please check one):
0-44,660
44,660.01-59,397.80
59,397.81-74,135.60
74,135.61-89,320
Other
Household Size (Include yourself):
Yearly Household Income:
Signature
Date
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Year
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