Healthwatch Harrow want to find out more about you and your experience of local health and social care. This is so we can help make local services better. Please respond to the questions below, and have your say!

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* 1. Age - What is your age group?

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* 2. Disability - Do you consider yourself to have a disability or long-term condition?

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* 3. Disability - If you said yes, please tell us about your disability / condition (you can choose one or more answers).

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* 4. Ethnic origin - What is your ethnic origin?

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* 5. Religion - What is your religion?

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* 6. Carer status - Are you a carer for a vulnerable person?

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* 7. Sex - Are you?

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* 8. Gender - Is your gender identity the same as the gender you were assigned at birth? (If you identify as transgender or transsexual, please select ‘No’)

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* 9. Sexual orientation - Are you?

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* 10. Have your say - Please tell us about your health or social care experience below:

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* 11. First Name - What is your first name? (Optional)

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* 12. Last Name - What is your last name? (Optional)

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* 13. Contact information - What is your email address? (Optional)

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* 14. Contact information - What is your phone number? (Optional)

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* 15. Future contact - Would you like to receive our newsletter and information about other Healthwatch Harrow events in future? (Optional)

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