Patient Demographics, Capacity and Referral Patterns

1. Patient Demographics, Capacity, and Referral Patterns

Question Title

* 1. Facility Name:

Question Title

* 2. What percentage of your patients belong to each of the following demographic categories?

	None	Less than 10%	10%-33%	34%-66%	67%-99%	All
Patients under 18 years of age	Patients under 18 years of age None	Patients under 18 years of age Less than 10%	Patients under 18 years of age 10%-33%	Patients under 18 years of age 34%-66%	Patients under 18 years of age 67%-99%	Patients under 18 years of age All
Patients over 50 years of age	Patients over 50 years of age None	Patients over 50 years of age Less than 10%	Patients over 50 years of age 10%-33%	Patients over 50 years of age 34%-66%	Patients over 50 years of age 67%-99%	Patients over 50 years of age All
Female patients	Female patients None	Female patients Less than 10%	Female patients 10%-33%	Female patients 34%-66%	Female patients 67%-99%	Female patients All

N/A

<10%

10-33%

34%-66%

67%-90%

>90%

Infrequently

Sometimes

Frequently

Yes

If Yes, please list the hospitals and clinics where you refer your patients. Please also note the distance from your facility to these places.

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50% of survey complete.