| Question | Response |
|---|---|
| Sex | Male Female |
| Age | |
| Age units | Years Months Days |
| Ethnicity | Hispanic or Latino Not Hispanic or Latino Not Applicable |
| Race | American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Unknown Not Reported |
| Specify if Race is ?Other? | |
| Date of birth | |
| Is subject of child bearing status | Able to bear children Premenarche Post-Menopausal Sterile - of child bearing age |