About You

This helps us to understand the different needs for all our communities.

Is your care with us for...

Women's Health

Children's Health

Mental Health Services (FTB)

My care was...

Who looked after you?

Your recent appointment / visit - Was it?

In person (face to face) visit

Telephone Consultation

Video Call

Not applicable / other

Are you a...

Patient

Partner

Parent/Carer

Visitor

Other

Age group of person receiving care

Your gender (Optional)

The following details are OPTIONAL and can help us to understand the different needs for all our communities.

Female

Male

Non-binary

Transgender

Other

Prefer not to say

Your ethnicity (Optional)

Your sexual orientation (Optional)

The following details are OPTIONAL and can help us to understand the different needs for all our communities.

Bi-sexual

Heterosexual/straight

Gay

Lesbian

Other

Prefer not to say

Your religion (Optional)

The following details are OPTIONAL and can help us to understand the different needs for all our communities.

Buddhist

Christian

Jewish

Hindu

Muslim

Sikh

Other

No religion

Prefer not to say

Your disability (Optional)

The following details are OPTIONAL and can help us to understand the different needs for all our communities.

Yes

Prefer not to say