Extended Access Service - Patient Input

About You

Knowing a bit more about you helps us to fully understand the information we gather to improve our services.

Question Title

* 1. What age bracket do you fall into?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Prefer Not to Answer

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* 2. What gender are you?

Male

Female

Non-Binary

Prefer Not to Answer

Other (please specify)

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* 3. What is your ethnicity?

Asian/Asian British

Black/Black British/Caribbean/African

Mixed/Multiple Ethnic Groups

Traveller/Roma/Gypsy

White (incl. British, Irish, Other)

Prefer Not to Answer

Other (please specify)

Question Title

* 4. What is your employment status?

Employed - Full-Time

Employed - Part-Time

Self-Employed

Not Employed and Looking for Work

Not Employed and Not Looking for Work

Carer

Retired

Student

Homemaker

Prefer Not to Answer

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* 5. What is your preferred method of travel?

Car

Bus / Public Transport

Taxi

Bike

Travel by Foot

Prefer Not to Answer

Extended Access Service - Patient Input

About You

Question Title

* 1. What age bracket do you fall into?

Question Title

* 2. What gender are you?

Question Title

* 3. What is your ethnicity?

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* 4. What is your employment status?

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* 5. What is your preferred method of travel?

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* 6. Which GP Practice are you registered at?