| 45392-8 | Patient First name | |
| 45392-8 | Patient First name | |
| 45394-4 | Patient Last name | |
| 45394-4 | Patient Last name | |
| 56799-0 | Address | |
| 56799-0 | Address | |
| 68997-6 | City:Loc:Pt:^Patient:Nom: | |
| 68997-6 | City:Loc:Pt:^Patient:Nom: | |
| 46499-0 | State of residence | |
| 46499-0 | State of residence | |
| 45401-7 | Postal code | |
| 45401-7 | Postal code | |
| 87721-7 | County of residence | |
| 87721-7 | County of residence | |
| 66477-1 | Country of current residence | |
| 66477-1 | Country of current residence | |
| 79183-0 | First name Guardian | |
| 79183-0 | First name Guardian | |
| 79184-8 | Last name Guardian | |
| 79184-8 | Last name Guardian | |
| 42077-8 | Phone # | |
| 42077-8 | Phone # | |
| 76458-9 | Patient Email address | |
| 76458-9 | Patient Email address | |
| 32624-9 | Race | |
| 32624-9 | Race | |
| 69490-1 | Ethnicity OMB.1997 | |
| 69490-1 | Ethnicity OMB.1997 | |
| 79191-3 | Patient demographics Pnl | |