APTA Registry patient registration panel

Label	Value	Unit
Pt ID ?
Pt ID assign auth ?
Patient Last name
Patient First name
Patient middle name
Birth date		{mm/dd/yyyy}
Social Security #
Postal code
Sex:Type:Pt:^Patient:Nom:HL7.v3 ?
Race OMB.1997 ?
Ethnicity OMB.1997 ?
Marital status+living arrang
Patient Email address