| 67586-8 | You have been treated with less courtesy than other people:Find:RptPeriod:^Patient:Ord: | required |
| 67587-6 | You have been treated with less respect than other people:Find:RptPeriod:^Patient:Ord: | required |
| 67588-4 | You have received poorer service than other people at restaurants or stores:Find:RptPeriod:^Patient:Ord: | required |
| 67589-2 | People have acted as if they think you are not smart:Find:RptPeriod:^Patient:Ord: | required |
| 67590-0 | People have acted as if they are afraid of you:Find:RptPeriod:^Patient:Ord: | required |
| 67591-8 | People have acted as if they think you are dishonest:Find:RptPeriod:^Patient:Ord: | required |
| 67592-6 | People have acted as if they're better than you are:Find:RptPeriod:^Patient:Ord: | required |
| 67593-4 | You have been called names or insulted:Find:RptPeriod:^Patient:Ord: | required |
| 67594-2 | You have been threatened or harassed:Find:RptPeriod:^Patient:Ord: | required |
| 67580-1 | What do you think was the main reason for this experience:Find:RptPeriod:^Patient:Nom: | optional |
| 112307-4 | The Everyday Discrimination Scale:-:RptPeriod:^Patient:-:EDS | required |