Parkwaygeneralsurgeons.com



Parkway General SurgeonsParkway Surgical CenterEthnicity, Race & LanguageWhy are we asking?The mission of Parkway General Surgeons/Parkway Surgical Center is to plan for and support the development of a healthcare system that meets the current and future healthcare needs of all of our patients, no matter their background. In doing so, we ask that you assist us in providing this information by making the most appropriate selection regarding race and ethnicity from the choices listed below.Patient Name: ________________________________________ Date of Birth: ____________ Date: ________Do you identify your race as (Circle any you feel apply):AsianA person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.Native Hawaiian A person having origins in any of the original peoples of Hawaii.Other Pacific IslanderA person having origins in any of the original peoples of Guam, Samoa, or other Pacific Islands.Black/Haitian or African AmericanA person having origins in any of the black racial groups of Africa.American Indian/Alaskan NativeA person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.WhiteA person having origins in any of the original peoples of Europe, the Middle East, or North Africa.DeclineI’d rather not answer.Do you identify your ethnicity as (Circle One):(Descriptions are the standard used by civil rights compliance reporting)Hispanic/LatinoA person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.Non-Hispanic/LatinoAll OthersPlease identify your preferred language for communication (Circle One):EnglishArabicFrenchPortugueseSlovakVietnameseBosnianGermanPunjabiSpanishCantoneseItalianRussianSomaliFarsiJapaneseSerbianThaiFilipino (Tagalog)Korean MandarinSign LanguageUkrainian UrduOther: ___________ ................
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