Skip to content
CrescentCare Patient Satisfaction Survey
Demographics
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)
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)
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)
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)
Age Range
Under 18
18-24
25-34
35-44
45-54
55-64
65+
