CrescentCare Patient Satisfaction Survey

Demographics

Question Title

* Race

Black/African American

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native Hawaiian

Other Pacific Islander

Guamanian or Chamorro

Samoan

American Indian/Alaska Native

White

More than one race

I'd rather not disclose my race

Other (please specify)

Question Title

* Ethnicity

Mexican, Mexican American, Chicano/a

Puerto Rican

Cuban

Not Hispanic, Latino/a, or Spanish Origin

I'd rather not disclose my ethnicity

Other (please specify)

Question Title

* Sexual Orientation

Lesbian

Gay

Bisexual

Heterosexual (or straight)

I don't know my sexual orientation

I would rather not disclose my sexual orientation

Other (please specify)

Question Title

* Gender Identity

Male/Man

Female/Woman

Transgender Man/Transgender Male/Transmasculine

Transgender Woman/Transgender Female/Transfeminine

Non-Binary/Genderqueer

I'd rather not disclose my gender identity

Other (please specify)

Question Title

* Age Range

Under 18

18-24

25-34

35-44

45-54

55-64

65+