Montefiore Einstein Primary Care Research Intake Form

The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

Working...

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Montefiore Einstein Primary Care Research Intake Form

What is your race and/or ethnicity?
Select all that apply and enter additional details in the spaces below.
Note, you may report more than one group.

American Indian or Alaska Native

Asian

'Individuals from disadvantaged backgrounds' is defined as those who meet two or more of the following criteria:

You have selected an option that triggers this survey to end right now.

Montefiore Einstein Primary Care Research Intake Form

What is your race and/or ethnicity?Select all that apply and enter additional details in the spaces below.Note, you may report more than one group.

American Indian or Alaska Native

Asian

'Individuals from disadvantaged backgrounds' is defined as those who meet two or more of the following criteria:

You have selected an option that triggers this survey to end right now.

What is your race and/or ethnicity?
Select all that apply and enter additional details in the spaces below.
Note, you may report more than one group.