3.10 Demographic and Biological Data
Demographic and biographic data includes basic characteristics about the patient, such as their name, contact information, birthdate, age, gender and preferred pronouns, allergies, languages spoken and preferred language, relationship status, occupation, and resuscitation status. See Table 3.1 for sample focused questions used to gather demographic and biological data.
| Data | Focused Interview Questions |
|---|---|
| Name
Contact Information Emergency Contact Information |
What is your full name?
What do you prefer to be called? What is your address? What is your phone number? Whom can we contact in an emergency? What is their relationship to you? At what number can we contact them? |
| Birthdate
Age |
What is your birthdate?
What is your current age? |
| Gender | What is your biological gender?
With what gender do you identify? What are your preferred pronouns (he/him/his, she/her/hers, them/they/theirs, etc.)? |
| Allergies | Do you have any allergies?
How do you react to each allergen? |
| Preferred Language | What is your primary language that you prefer to speak?
Note: If English is not their primary language, offer to obtain a medical interpreter as needed. |
| Relationship Status | Tell me about your relationship status.
*Avoid questions that imply expected behaviors, such as:
|
| Occupation and Education | What is your occupation?
Where do you work or go to school? What is the highest level of education you have completed? |
| Resuscitation Status | Have you considered preferences for resuscitation, also called CPR, if your heart stops or you stop breathing?
Do you have any advance directives on file with a hospital or provider, such as a “Living Will” or “Power of Attorney for Health Care”? Would you like more information about advance directives? |
See Table 3.2 for a sample demographic form used during a complete health history.
|
Demographic Information Form Interview Date: Patient Name: Address: Emergency Contact Name: Relationship:
Date of Birth: Age: Sex: Male / Female / Another Option Gender You Self-Identify With: Preferred Pronouns:
Allergies:
Primary Language: Interpreter needed: Yes / No
Relationship Status:
Occupation/Education:
Resuscitation Status:
Information from: Patient / Other Patient Accompanied: Yes / No Details: |
|---|
Attribution
This section contains material taken from The Complete Subjective Health Assessment by Jennifer Lapum, Oona St-Amant, Michelle Hughes, Paul Petrie, Sherry Morrell, and Sita Mistry and is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
