Join our Health Forum A little bit more about you... Question Title * 1. Address Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 2. Do you have a disability? Yes No Question Title * 3. Are you already involved in a health-related voluntary or patient group? Yes No Prefer not to say Question Title * 4. If yes, which one? Question Title * 5. Are you a carer? Yes No Prefer not to say Question Title * 6. GP Practice (we will not be contacting your practice - this information is used for administration of the Health Forum membership) Question Title * 7. Areas of health and social care you are interested in (please tick all that apply) Cancer Care/ nursing home Carers Children and young people's health Community care (such as district nursing, podiatry etc) Emergency care (such as ambulance, A&E) End of life care Equality and Diversity Health and Wellbeing (such as illness prevention) Hospital care (in-patient or out-patient) Learning disabilities Long-term conditions Maternity Medicines Men's health Mental health Older people's health Out of hours care Primary care (such as GP, optometry, dentistry, pharmacy) Self care Women's health Other interests (please specify) Question Title * 8. Ethnicity White - British White - Irish White - Gypsy/traveller White - Other white background Black or Black British - Caribbean Black or Black British - African Black or Black British - other black background Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - other Asian background Mixed - White & Black Carribbean Mixed - White & Black African Mixed - White & Asian Mixed - other mixed background Question Title * 9. Religion and belief Buddhist Christian Hindu Jewish Muslim Sikh No religion/belief I do not wish to disclose Other (please specify) Question Title * 10. Disability Not applicable Learning disability Long standing illness mental health condition Physical impairment Sensory impairment Other disability (please specify) Question Title * 11. Sexual orientation Heterosexual Lesbian Gay Bisexual Prefer not to say Question Title * 12. Gender Male Female I do not wish to disclose Question Title * 13. Pregnancy and maternity (Are you pregnant or on maternity leave?) Yes No Prefer not to say Not applicable Question Title * 14. Is your gender the one assigned to you at birth Yes No Prefer not to say Question Title * 15. Marital status and civil partnership Civil partnership Divorced Living with someone Married Separated Single Widowed Prefer not to say Done
