Date of birth: Gender: Male Unspecified Female Not reported Unknown Ethnicity(“X” ONLY one with which you MOST CLOSELY identify): Hispanic or Latino Unknown Not Hispanic or Latino Not Reported Race category (choose all that apply): American Indian or Alaska Native White Asian Unknown Black or African American Not Reported Native Hawaiian or Other Pacific Islander Medical History Term: Number of years of education: years: SNOMED CT Code:
Date of birth: Gender: Male Female Unknown Unspecified Not reported Ethnicity(“X” ONLY one with which you MOST CLOSELY identify): Hispanic or Latino Not Hispanic or Latino Unknown Not Reported Race category (choose all that apply): American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Unknown Not Reported Number of years of education: years: SNOMED CT Code: Medical History Term:
F1807_General_Core.docx