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by chris
May 8, 2025May 8, 2025

Demographics / Contact Template (1)

Please select your GP Practice(Required)

This would be your local practice

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Other

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Please tell me about your experience?

Please tell select the applicable options about GP 1?

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Select between 1 and 3 choices.

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If you are experiencing mental health issues, please call: 01482 283943

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Basic Demographics

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Healthwatch collects demographic data which is used to generate insights and understand health inequalities, including challenges some groups face in accessing health and social care services.

As part of your experience, we would like you to provide some basic demographic data below to help us in our mission to improve local services.

What is your age range?(Required)

What is your ethnicity?(Required)

What is your gender?(Required)

Are you or do you consider yourself to be disabled?(Required)

Yes

No

Do you or do you consider yourself to have a long-term condition?(Required)

Yes

No

Thank you for completing the above demographic questions.

We do also record more detailed demographic information which will help us further, however this is completely optional.

Would you like to provide any further demographic information?(Required)

Yes

No

This field is hidden when viewing the form

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Please can you tell us your nationality?

Is your gender identity the same as recorded at birth?

What is your sexual orientation?

What is your religion or belief?

What is your marital and civil partnership status?

If you are currently pregnant or have recently given birth, please select if any of the following apply:

Currently pregnant

Currently breastfeeding

Given birth in the last 26 weeks

Would you consider yourself to be from a seldom-heard group or community?

The term 'seldom-heard groups' refers to under-represented people who use or might potentially use health or social services and who are less likely to be heard by these service professionals and decision-makers.

Yes

No

This field is hidden when viewing the form

If they select that they have a disability

You told us previously that you are or consider yourself to be disabled.

Please could you be able to tell us what type of disability you have?

You can select more than one

Physical or mobility impairment

Sensory impairment

Learning disability or difficulties

Mental health condition

Long term condition

Other

This field is hidden when viewing the form

If they select that they have a long-term condition

You told us previously that you are or consider yourself to be disabled.

Please could you be able to tell us what type of long-term condition you have?

You can select more than one

Asthma, COPD or respiratory condition

Blindness or severe visual impairment

Cancer

Cardiovascular condition (including stroke)

Chronic kidney disease

Deafness or severe hearing impairment

Dementia

Diabetes

Epilepsy

Hypertension

Learning disability

Mental health condition

Musculoskeletal condition

Other

Contacting You

Do you want to be contacted by Healthwatch about your experience?(Required)

Yes

No

This field is hidden when viewing the form

Contact Details

Please tell us your name(Required)

First Last

Telephone Number

Email Address

If you want to be contacted by letter, please provide your address below

Street Address Address Line 2 City ZIP / Postal Code

Number

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