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Pediatric Sleep Medicine
New Patient Questionnaire
Date:Child\'s Name:Birthdate:Age:Address:
Gender:Phone:
Racial/Ethnic background:Person lying out
questionnaire:
Relationship to the patient:
Who
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What is racialethnic background?
Racial/ethnic background refers to a person's race or ethnicity.
Who is required to file racialethnic background?
Certain organizations or institutions may be required by law to collect and report racial/ethnic background information.
How to fill out racialethnic background?
Racial/ethnic background can be filled out by providing information about race and ethnicity either through checkboxes or write-in responses.
What is the purpose of racialethnic background?
The purpose of collecting racial/ethnic background information is to monitor and address issues related to discrimination and inequality.
What information must be reported on racialethnic background?
Information on race and ethnicity such as African American, Hispanic, Asian, Caucasian, etc.
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