Space to Breathe Equality Monitoring Survey

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* 1. First please tell us the start of your postcode and GP Practice (leave blank or part filled if you'd rather not say)

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* 2. What is your gender?

Male

Female

Other

Rather not say

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* 3. Is your gender identity now different to the sex you were assumed to be at birth?

Yes

Prefer not to say

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* 4. What is your age?

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* 5. What is your sexual orientation?

Bisexual (both sexes)

Lesbian (same sex)

Gay man (same sex)

Heterosexual/Straight (opposite sex)

Other

Prefer not to say

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* 6. What is your ethnic background?

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* 7. Do you consider yourself belong to any religion?

Buddhism

Christianity

Hindusim

Islam

Judaism

Sikhism

No religion

Prefer not to say

Other

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* 8. Do you consider yourself disabled? If yes what type of disability or impairment do you have? (if no please leave blank)

Autism

Learning disability

Mental Health condition

Physical or mobility

Hearing

Visual

Long standing health condition or illness

Prefer not to say

Other

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* 9. How good or bad is your health today, very bad being 1, very well being 10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 10. Do you provide care for someone?

Yes

Prefer not to say