Dummy Patient Experience Page - NHS Shropshire, Telford and Wrekin

Your First Name

Your Email Address (This will be our most common form of communication)

We would like to know a little more about you. The following questions will help us understand who has joined our network and help to ensure we are engaging with a wide section of the community. It also helps us make sure that the surveys that we send you are relevant and useful.

Please provide your full postcode

What is your ethnic group?

Other ethnic group:

How old are you?

What is your religion?

Other Religion:

How do you describe your gender identity?

Other gender identity

What is your sexual orientation?

Other sexual orientation

What is your relationship status?

Other relationship status

Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months?

Do you consider yourself to have a disability? (The Equality Act 2010 states a person has a disability if they have a physical or mental impairment which has a long-term (12 month period or longer) or substantial adverse effects on their ability to carry out day-to-day activities).

Other disability

Please describe:

Are you the parent or guardian of a child / children under the age of 18?

Do you provide care for someone? A carer is defined as anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support. (Tick as many as appropriate.)

Have you ever served in the armed services?

I consent to receiving surveys and information on other engagement opportunities related to my membership of the People's Network