Please indicate if you or your close family have any of the following conditions: You Mother Father Brother Sister Asthma Diabetes Angina or Heart Attack Stroke High Blood Pressure Epilepsy Cancer Mental Health Problems Thyroid Problems High Cholesterol Ethnicity - Information about your ethnic background allows us to make sure our services reflect the needs of everyone in our patient population. Ethnic category 2001 census British White British Asian British Black □ □ □ Other Mixed British Polish Other European □ □ □ Asian African Americas □ □ □ Other White Other Mixed Any Other □ □ □ Background Background Prefer not to say □ What is your first language? Do you require an language interpreter YES or NO Do you have any information or Large Print Braille BSL interpreter communication needs? Please circle Deafblind Manual Interpreter and discuss with a receptionist. An Advocate Other Assistance
Please indicate if you or your close family have any of the following conditions: You Mother Father Brother Sister Asthma Diabetes Angina or Heart Attack Stroke High Blood Pressure Epilepsy Cancer Mental Health Problems Thyroid Problems High Cholesterol Ethnicity - Information about your ethnic background allows us to make sure our services reflect the needs of everyone in our patient population. Ethnic category 2001 census British White □ British Asian □ British Black □ Other Mixed British □ Polish □ Other European □ Asian □ African □ Americas □ Other White Background □ Other Mixed Background □ Any Other □ Prefer not to say □ What is your first language? Do you require an language interpreter YES or NO Do you have any information or communication needs? Please circle and discuss with a receptionist. Large Print Braille BSL interpreter Deafblind Manual Interpreter An Advocate Other Assistance