7. Do you consider yourself to be disabled? 9. Are you pregnant? Yes No Yes No Prefer not to say Prefer not to say 10. Have you given birth in the last 6 months? Type of impairment: Yes No Please tick all that apply Prefer not to say Physical or mobility impairment 11. What is your sexual orientation? (such as using a wheelchair to get around and / or Bisexual (both sexes) difficulty using their arms) Gay (same sex) Sensory impairment Heterosexual/straight (opposite sex) (such as being blind / having a serious visual Lesbian (same sex) impairment or being deaf / having a serious hearing Other impairment) Prefer not to say Mental health condition 12. Are you transgender? (such as depression or schizophrenia) Is your gender identity different to the sex you Learning disability were assumed at birth? (such as Downs syndrome or dyslexia) or cognitive Yes No impairment (such as autism or head-injury) Prefer not to say Long term condition (such as cancer, HIV, diabetes, chronic heart disease, or epilepsy) Prefer not to say 8. 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 ill-health or problems related to age? Yes No Prefer not to say Thank you for taking the time to complete this survey. Please return to: FREEPOST RTEJ-AGSA-UAZL NHS North Kirklees CCG 4th Floor Empire House Wakefield Old Road Dewsbury WF12 8DJ Please return no later than Sunday 27 November 2016. Unfortunately, we cannot accept any responses after this date.
7. 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 8. 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 ill-health or problems related to age? Yes No Prefer not to say 9. Are you pregnant? Yes No Prefer not to say 10. Have you given birth in the last 6 months? Yes No Prefer not to say 11. What is your sexual orientation? Bisexual (both sexes) Gay (same sex) Heterosexual/straight (opposite sex) Lesbian (same sex) Other Prefer not to say 12. Are you transgender? Is your gender identity different to the sex you were assumed at birth? Yes No Prefer not to say Thank you for taking the time to complete this survey. Please return to: FREEPOST RTEJ-AGSA-UAZL NHS North Kirklees CCG 4th Floor Empire House Wakefield Old Road Dewsbury WF12 8DJ Please return no later than Sunday 27 November 2016. Unfortunately, we cannot accept any responses after this date.
Talk-health-Kirklees-survey.docx