Do you consider yourself to be Hispanic or Latino? Select one.
Hispanic or Latino
A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture of origin, regardless of race
Not Hispanic or Latino
I do not wish to provide this information or the patient's ethnicity is unknown
What race do you consider yourself to be? Select one or more of the following.
American Indian or Alaskan Native
A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliation or community attachment
Asian
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
Black or African American
A person having origins in any of the black racial groups of Africa
Native Hawaiian or Other Pacific Islander
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
White
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
I do not wish to provide this information or the patient's race is unknown
