Your Health, Your Say

							Your Health, Your Say
Booking Form
Thank you for your interest in our ‘Your Health, Your Say’ event which takes place on
Thursday 24 January 2013. Please take a few minutes to read through our introduction to the
day and fill in the short survey. Filling in this form will help us ensure that we get feedback
from all the different communities in our area.

Any information is kept in strict confidence. Please return completed booking forms by Monday
21 January 2013 to:

NHS Leeds South and East CCG (Event), Freepost RLSJ – BXBH – HZRL,
North West House, Leeds, LS16 6QG

Or email it to debra.backhouse@nhs.net

The Event will:
 have the opportunity to work with us to talk about the health needs that matter to you and
   your community;
 work with us to help prioritise the areas of health that you think are most important to
   people in locally; and
 provide information which will help Leeds South and East Clinical Commissioning Group to
   develop services that meet the needs and aspirations of communities in Leeds South and
   East.

  Name                                Email                                Telephone number


  Address                                               Special requirements (diet/transport)


                           Postcode
  Please note that out of pocket expenses such as travel and childcare/care costs can be claimed if we are
  informed before you attend the event. They will not be reimbursed on the day.

1. Who are you representing at today’s event               The public                         Service user
   (please tick all that apply)
                                                               Carers

2. What are your particular interests around                 Diabetes        Mental Health          Cancer
   health (please tick all that apply)
                                                          Addiction           Heart Disease         Obesity
                                                      Long Term
                                                      Conditions                    Other (please specify)

3. Have you attended an NHS ‘involvement’                                          Yes                   No
   event (such as a Patient Group or
   Consultation event) before?

                                     Continues over the page
Are you?
                           Male                          Female
           Heterosexual/Straight            Lesbian/gay woman                            Gay man
                       Bisexual
                       Under 16                          17 – 24                           25 – 34
                        35 – 44                          45 – 54                           55 – 64
                        65 – 74                          75 – 84                               84+
                   White British                      White Irish          Gypsy or Irish traveller
  Mixed White & Black Caribbean     Mixed White & Black African           Mixed White and Asian
     Asian/Asian British Indian     Asian/Asian British Pakistani   Asian/Asian British Bangladeshi
 Black/Black British Caribbean        Black/Black British African
                     Chinese                                Arab                             Other
   Do you consider yourself to be                            Yes                                 No
                      disabled?