NAME: To help us ensure that our contact list represents our local community,
please indicate with which of the following ethnic background you would
EMAIL ADDRESS: closely identify
British Group Irish Other
POST CODE: White & Black White & Black White & Asian
ASIAN or ASIAN
By which method would you prefer us to contact you? Indian Pakistani Bangladeshi
BLACK or BLACK
o Email BRITISH
o Telephone Caribbean African
CHINESE or other
Are you? Male [ ] Female [ ] Chinese Any other
How would you describe how often you come to the practice?
To help us ensure that we have a fair representation of our practice
Regularly  population please answer the following:
Occasionally  Do you suffer from chronic health issues, e.g. diabetes, heart disease?
Very rarely  If yes, what do you suffer from?
AGE GROUP 18 and 50 – 59
19 – 29 60 – 69 Are you a registered carer?
30 – 39 70 – 79
40 - 49 80+