5. Do you consider yourself to be disabled? 7. Are you pregnant? Yes No Yes No Prefer not to say Prefer not to say Type of impairment: Please tick all that apply 8. Have you birth in the last 6 months? Yes No Physical or mobility impairment (such as using a wheelchair to get around Prefer not to say and / or difficulty using their arms) Sensory impairment 9. Please select the option that best (such as being blind / having a serious represents your sexual orientation? visual impairment or being deaf / having a Bisexual (both serious hearing impairment) Gay (same sex) Mental health condition Heterosexual/straight (opposite sex) (such as depression or schizophrenia) Lesbian (same sex) Learning disability (such as Downs syndrome or dyslexia) or Prefer not to say cognitive impairment (such as autism or head-injury) 10. Are you transgender? Long term condition Is your gender identity different to the gender (such as cancer, HIV, diabetes, chronic you were assigned at birth? heart disease, or epilepsy) Yes No Prefer not to say Prefer not to say 6. Are you a carer? 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 or problems related to age? Yes No Prefer not to say Thank you for completing this form
5. Do you consider yourself to be disabled? Yes No Prefer not to say Type of impairment: Please tick all that apply Physical or mobility impairment (such as using a wheelchair to get around and / or difficulty using their arms) Sensory impairment (such as being blind / having a serious visual impairment or being deaf / having a serious hearing impairment) Mental health condition (such as depression or schizophrenia) Learning disability (such as Downs syndrome or dyslexia) or cognitive impairment (such as autism or head-injury) Long term condition (such as cancer, HIV, diabetes, chronic heart disease, or epilepsy) Prefer not to say 6. Are you a carer? 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 or problems related to age? Yes No Prefer not to say 7. Are you pregnant? Yes No Prefer not to say 8. Have you birth in the last 6 months? Yes No Prefer not to say 9. Please select the option that best represents your sexual orientation? Bisexual (both Gay (same sex) Heterosexual/straight (opposite sex) Lesbian (same sex) Prefer not to say 10. Are you transgender? Is your gender identity different to the gender you were assigned at birth? Yes No Prefer not to say Thank you for completing this form
IFR-Referral-Form-February-2017-GHCCG-NKCCG-v1.0.docx