ETHNICITY White English Welsh Scottish Irish Northern Irish □ □ □ □ □ Any other White background, please specify □ …………………………………………………… Mixed and Black Caribbean White and Asian White and Black African □ □ □ Any other Mixed background, please specify □ …………………………………………………… Asian, Asian British, Asian English, Asian Scottish or Asian Welsh Indian Pakistani Bangladeshi □ □ □ Any other Asian background, please specify □ …………………………………………………… Black, Black British, Black English, Black Scottish or Black Welsh Caribbean African □ □ Any Black background, please specify □ …………………………………………………… Chinese, Chinese British, Chinese English, Chinese Scottish, Chinese Welsh or Other Ethnic Group Chinese □ Any other Chinese background, please specify □ ……………………………………………….. LANGUAGE What is your first language? _________________________________________________________ If English is not your first language, would you require an Interpreter at appointments? (If yes, please list what language they would need to speak)______________________________________________________________ MEDICAL Diagnosis _________________________________________________ Date of diagnosis___________________________________________
ETHNICITY White □ English □ Welsh □ Scottish □ Irish □ Northern Irish □ Any other White background, please specify …………………………………………………… Mixed □ and Black Caribbean □ White and Asian □ White and Black African □ Any other Mixed background, please specify …………………………………………………… Asian, Asian British, Asian English, Asian Scottish or Asian Welsh □ Indian □ Pakistani □ Bangladeshi □ Any other Asian background, please specify …………………………………………………… Black, Black British, Black English, Black Scottish or Black Welsh □ Caribbean □ African □ Any Black background, please specify …………………………………………………… Chinese, Chinese British, Chinese English, Chinese Scottish, Chinese Welsh or Other Ethnic Group □ Chinese □ Any other Chinese background, please specify ……………………………………………….. LANGUAGE What is your first language? _________________________________________________________ If English is not your first language, would you require an Interpreter at appointments? (If yes, please list what language they would need to speak)______________________________________________________________ MEDICAL Diagnosis _________________________________________________ Date of diagnosis___________________________________________
Transition%20passport%20for%20metabolic%20patients.docx