Your Views on a New Appointment System 1. Question Title * 1. How often do you use the Medical Centre? Less than once a year Once a year Every six months Every three months Every month More often than once per month Never OK Question Title * 2. What is your most common reason for visiting the Medical Centre? To see the doctor To see a nurse Collect or order a prescription OK Question Title * 3. In order to ensure that we provide the best services for all of our communities, and to ensure that we do not knowingly discriminate against any section of our community, it is important for us to gather the following information. No personal information will be released when reporting statistical data and all information will be protected and stored securely in line with data protection rules. This information will be kept confidential and you do not have to answer all of these questions, but we would be very grateful if you would.Please tell us the first part of your postcode (e.g. S9, S35) OK Question Title * 4. What is your gender? Female Male Prefer not to say OK Question Title * 5. Transgender Is your gender identity different to the sex you were assumed to be at birth? Yes No Prefer not to say OK Question Title * 6. What age group are you in? 0-16 16-25 25-35 35-45 45-55 55-65 65-75 75-85 85+ OK Question Title * 7. What is your sexual orientation? Bisexual (both sexes) Lesbian Gay Man Heterosexual/Straight Prefer not to say OK Question Title * 8. What is your ethnic background? White British White Euorpean White non EU Mixed Race British Mixed Race non British Chinese Black African White African Asian Arab Indian Black Caribbean Gypsy/Traveller Pakistani Irish Other Asian background Other Black background Other Mixed/multiple ethnic background Prefer not to say OK Question Title * 9. Do you consider yourself to belong to any religion? Buddhism Christianity Hinduism Islam Judaism Sikhism Scientology No religion Prefer not to say OK Question Title * 10. Do you consider yourself to be disabled? The Equality Act 2010 states that a person has a disability if: ‘a person has a physical or mental impairment, and the impairment has a substantial and long-term adverse effect on that their ability to carry out normal day-to-day activities’ Yes No Prefer not to say OK Question Title * 11. If you have a disability, what type of disability do you have? Learning disability/difficulty Long-standing illness or health condition Mental Health condition Physical or mobility Hearing Visual Prefer not to say I do not consider myself to have a disability OK Question Title * 12. Do you provide care for someone? Such as family, friends, neighbours or others who are ill, disabled or who need support because they are older. Yes No Prefer not to say OK DONE