Equalities questions

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Please tell us which GP practice you are registered with.

List of GP practices in Enfield

Please enter the first part of your postcode e.g. EN1, N13

Please tell us your age

Under 21

21-30

31-40

41-50

51-60

61-64

65 and over

I do not wish to disclose this

Please tell us your gender

Male

Female

Transgender (Male)

Transgender (Female)

I do not wish to disclose this

Are you married or in a same sex civil partnership?

Yes

I do not wish to disclose this

Please select the option which best describes your sexuality

Lesbian/Gay woman

Gay man

Bisexual

Hetrosexual/straight

I do not wish to disclose this

Do you consider yourself to have a disability?

Yes

I do not wish to disclose this

If you consider yourself to be disabled, please state the type of impairment that applies to you. People may experience more than one type of impairment, so please feel free to tick more than one box. If none of the categories apply, please mark "other" and specify the type of impairment.

Physical impairment

Sensory impairment

Mental health condition

Learning disability/difficulty

Long-standing illness

Other

I do not wish to disclose this

Other (please specify):

This is required

Do you provide care on a substantial and regular basis for a family member or friend who needs care/help/support because of sickness, frailty or disability?

Yes

I do not wish to disclose this

Equalities questions

Please tell us which GP practice you are registered with.

Please enter the first part of your postcode e.g. EN1, N13

Please tell us your age

Please tell us your gender

Are you married or in a same sex civil partnership?

Please select the option which best describes your sexuality

Please indicate your religion or belief

I would describe my ethnic origin as

Do you consider yourself to have a disability?

If you consider yourself to be disabled, please state the type of impairment that applies to you. People may experience more than one type of impairment, so please feel free to tick more than one box. If none of the categories apply, please mark "other" and specify the type of impairment.

Do you provide care on a substantial and regular basis for a family member or friend who needs care/help/support because of sickness, frailty or disability?

Equalities questions

Page 1

Please tell us which GP practice you are registered with.

Please enter the first part of your postcode e.g. EN1, N13

Please tell us your age

Please tell us your gender

Are you married or in a same sex civil partnership?

Please select the option which best describes your sexuality

Please indicate your religion or belief

I would describe my ethnic origin as

Do you consider yourself to have a disability?

If you consider yourself to be disabled, please state the type of impairment that applies to you. People may experience more than one type of impairment, so please feel free to tick more than one box. If none of the categories apply, please mark "other" and specify the type of impairment.

Do you provide care on a substantial and regular basis for a family member or friend who needs care/help/support because of sickness, frailty or disability?