Member type	Public Staff Patient
Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Wing Commander Capt Col Major Commodore Cllr Sister Master Lady Mayor Lieutenant colonel Reverend Dr Sir Baroness
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Preferred method of contact	Email Post Telephone SMS
Ethnicity	Not stated White - English, Welsh, Scottish, Northern Irish, British White - Irish White - Gypsy or Irish Traveller White - Other Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Other Mixed 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 Black or Black British - African Black or Black British - Caribbean Black or Black British - Other Black Other Ethnic Group - Arab Other Ethnic Group - Any Other Ethnic Group

Do you consider yourself to be disabled?	No Yes A sensory disability A physical disability A learning disability A mental health problem Any other special need (please list in the 'Notes' section)
Would you like to be involved?	Stand for election as a Governor Comment on general hospital patient information Take part on surveys & consultations on Trust’s plans Sit on a patient panel Join a website user group Attend or speak at trust committees Input into service design/redesign Volunteer at the Trust Support work done by the charities
Service preferences	Congenital Heart Disease Coronary Artery Disease Heart Valve Disease Cardiac arrhythmias Critical Care Other cardiac disease Cystic fibrosis Asthma Chronic Obstructive Pulmonary Disease Interstitial Lung Disease Other Respiratory Disease Transplantation
How are you connected with the Trust?	Current or former patient of Royal Brompton Hospital (within the last 3 years) Current or former patient of Harefield Hospital (within the last 3 years) Interested member of the public Carer of a current/former patient of Royal Brompton Hospital (within the last 3 years) Former RBHT staff member
How did you hear about the Trust?	Patient Mailing Trust website Through an employee of the Trust

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Title
First name
Last name
Middle name
Date of birth
Gender
Address
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Country	UK
Home telephone
Mobile
Email
Ethnicity
Preferred method of contact
Do you consider yourself to be disabled?
Would you like to be involved?
Service preferences
How are you connected with the Trust?
How did you hear about the Trust?

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