Please state which ethnic group you consider yourself to be: Prefer not to say …………………………………………. Please tell us your religion or belief: Prefer not to say …………………………………………. Do you consider yourself to have a long-standing illness or disability? Yes No Do you care for someone with a long-standing illness or disability? Yes No How would you describe your sexuality? Heterosexual or straight Prefer not to say Bisexual Other ………………………………. Gay or lesbian Are you are pregnant or do you have a child under two years old? Yes No Prefer not to say Have you undergone gender reassignment? Yes No Prefer not to say
Please state which ethnic group you consider yourself to be: …………………………………………. Prefer not to say Please tell us your religion or belief: …………………………………………. Prefer not to say Do you consider yourself to have a long-standing illness or disability? Yes No Do you care for someone with a long-standing illness or disability? Yes No How would you describe your sexuality? Heterosexual or straight Bisexual Gay or lesbian Prefer not to say Other ………………………………. Are you are pregnant or do you have a child under two years old? Yes No Prefer not to say Have you undergone gender reassignment? Yes No Prefer not to say
HaST_FHWConsult_Narrative_WEB_010816.docx