Patient Demographics Form

Name (required):

Date of Birth (required):

NHS NO (Optional)

Have you changed address, phone number, or GP (all optional):

New Address:

New Postcode:

New Phone Number:

New GP Address:

Age. Are you:

Under 2525-3435-4455-6445-5465+

What is your ethnic group (Choose one option that best describes your ethnic group or background)

English/Welsh/Scottish/Northern Irish/BritishIrishGypsy or Irish TravellerRomaAny other White background, please describeWhite and Black CaribbeanWhite and Black AfricanWhite AsianAny other Mixed / Multiple ethnic background, please describeIndianPakistaniBangladeshiChineseAny other Asian background, please describeAfricanCaribbeanAny other Black / African Caribbean background, please describeArabAny other ethnic group, please describe

What is your main spoken language?

EnglishUrduArabicCantonesePolishI do not have a spoken languageBritish Sign LanguageBengaliOther (please say):

What is your religion?

No religionBuddhistSikhChristianMuslimHinduJewishPrefer not to sayAny other religion (please say)

Which of the following options best describes how you think of yourself?

Heterosexual or StraightGay or LesbianBisexualDo not know or not sureUndecidedPrefer not to sayPrefer to self-describe (please say)Other (please say)

Sex and gender identity - Which one of the following best describes you?

MaleFemaleIntersexNon-binaryPrefer not to sayPrefer to self-describe (please say)

Is the gender you identify with the same as your sex registered at birth?

YesNoPrefer not to say

Disability: Do you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply)

No known impairment, health condition or learning differenceA long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsyA mental health impairment, such as depression, schizophrenia or anxiety disorderA physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutchesA learning difficultyNeuro-diverse e.g. dyslexic, dyspraxic or AD(H)DD/deaf or hearing impairedBlind or have a visual impairment uncorrected by glassesAn impairment, health condition or learning difference that is not listed above (please say):Prefer not to say

Are you a British Sign Language user?

YesNo

Additional employment monitoring questions from this point

Marriage and Civil partnership. Are you:

Single, that is, never married and never registered in a civil partnership marriedMarriedSeparated, but still legally marriedDivorcedWidowedIn a registered civil partnershipSeparated, but still legally in a civil partnershipFormerly in a civil partnership which is now legally dissolvedSurviving partner from a civil partnership

Pregnancy and maternity

YesNoPrefer not to say

How we can help - Specialties

Rheumatology

Gastroenterology

Ear, Nose and Throat

Orthopaedic

General Surgery

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