EMAIL ADDRESS by vxK8P6u7

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									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

                                                             WHITE
                                                             British Group            Irish                           Other
TELEPHONE NUMBER:
                                                             MIXED
POST CODE:                                                   White & Black            White & Black              White & Asian
                                                             Caribbean                African
                                                             ASIAN or ASIAN
                                                             BRITISH
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
                                                             ethnic group
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
                  under
                 19 – 29              60 – 69                                      Are you a registered carer?
                 30 – 39              70 – 79
                 40 - 49               80+

								
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