Tell us what you think! 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!Please note, this is a general feedback form which is periodically reviewed. If you would like to raise an urgent issue, please contact us via email on info@healthwatchharrow.co.uk or telephone on 020 3432 2889. OK Question Title * 1. Age - What is your age group? Under 16 16 – 24 years 25 – 44 years 45 – 64 years 65 & over OK Question Title * 2. Disability - Do you consider yourself to have a disability or long-term condition? Yes No Prefer not to say OK Question Title * 3. Disability - If you said yes, please tell us about your disability / condition (you can choose one or more answers). Physical disability Learning disability Mental health condition Other (please specify) OK Question Title * 4. Ethnic origin - What is your ethnic origin? Asian or Asian British Indian Sri Lankan Bangladeshi Pakistani Afghan Chinese Arab Iranian Black or Black British African Somali Caribbean Mixed White and Black African Mixed White and Black Caribbean Mixed White and Asian White British (including English, Welsh, Scottish and Northern Irish) Albanian Gypsy / Irish Traveller Polish Romanian Other including other Asian, Black, Mixed or White backgrounds (please specify) OK Question Title * 5. Religion - What is your religion? Buddhism Christianity (all denominations) Hinduism Islam Jainism Judaism Sikh Zoroastrian No religion / Atheist / Agnostic Other (please specify) OK Question Title * 6. Carer status - Are you a carer for a vulnerable person? Yes No Prefer not to say OK Question Title * 7. Sex - Are you? Female Male Prefer not to say Other (please specify) OK Question Title * 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’) Yes No Prefer not to say OK Question Title * 9. Sexual orientation - Are you? Bisexual Gay woman / lesbian Gay man Heterosexual Prefer not to say Other (please specify) OK Question Title * 10. Have your say - Please tell us about your health or social care experience below: OK Question Title * 11. First Name - What is your first name? (Optional) OK Question Title * 12. Last Name - What is your last name? (Optional) OK Question Title * 13. Future contact - Would you like to receive our newsletter and information about other Healthwatch Harrow events in future? Yes No OK Question Title * 14. Contact information - If you answered question 13 with a yes, please share your email address. OK Question Title * 15. Contact information - What is your phone number? (Optional) OK DONE
