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1. Personal Information
Title
Not Stated
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Wing Commander
Capt
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Sir
Lord
First name *
Last name *
Date of birth *
DD
MM
YYYY
Gender
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Male
Female
Transgender
Prefer not to say
Please enter your postcode and click Get Address
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Twitter
Preferred method of contact
Email
Post
Telephone
SMS
Ethnic background
Prefer not to say
Not stated
White British
White Irish
Gypsy or Irish Traveller
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Asian/Asian British Indian
Asian/Asian British Pakistani
Asian/Asian British Bangladeshi
Chinese
Black/Black British African
Black/Black British Caribbean
Arab
Other (please state):
Religion/Belief
Buddhist
Catholic
Christian
Church of England
Hindu
Jewish
Methodist
Muslim
No religion
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Other
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Quaker
Sikh
Please select the option that best represents your sexual orientation
Not Stated
Heterosexual
Gay/Lesbian
Bi-sexual
Do not know / not sure
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Pregnancy and Maternity
Unspecified
Pregnant
Pregnant in last 26 months
Not pregnant
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Not applicable
Is your gender identity the same gender as you were assigned at birth?
Unspecified
Yes
No
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2. Additional Information
Special Postal Requirements
Large Print
Audio tapes
Braille
Other (please state)
Vegetarian
Mobility Requirement
Diabetic
Are you disabled? If yes what type of impairment. Tick all that apply.
No
Yes
Prefer not to say
A learning disability
A mental health problem
A physical disability
A sensory disability
Any other special need
Behaviour or emotional
Dietary Requirement
Hearing
Long standing illness
Do you look after or give any help or support to a family member, friend or neighbour because of a long term physical disability, mental ill health or problems related to age?
Yes
No
Prefer not to say
Previous carer
3. Review
Last Used Services
Title
First name
Last name
Date of birth
Gender
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
Twitter
Ethnic background
Religion/Belief
Please select the option that best represents your sexual orientation
Pregnancy and Maternity
Is your gender identity the same gender as you were assigned at birth?
Special Postal Requirements
Preferred method of contact
Are you disabled? If yes what type of impairment. Tick all that apply.
Do you look after or give any help or support to a family member, friend or neighbour because of a long term physical disability, mental ill health or problems related to age?
4. Finish
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