Patients Association member anonymous demographic questionnaire

Thank you for becoming a member of the Patients Association.

As we grow, we’d like to know a little more about who’s joining us. A person’s background affects their experiences of health and social care; as an organisation that represents everyone it’s important for us to know who joins as part of that responsibility.

Completing this anonymous questionnaire helps us understand who joins us and which communities may be underrepresented among our membership. Completing this questionnaire is voluntary and all data are collected anonymously and held in line with the General Data Protection Regulations (GDPR). Thank you.

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* 1. What is your age?

Under 18 years

18 to 24 years

25 to 49 years

50 to 64 years

65 to 79 years

80+ years

Prefer not to say

Not known

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* 2. What gender do you identify as?

A woman

A man

Non-binary

Intersex

Not known

Prefer to self describe

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* 3. Is your gender identity the same as the sex you were assigned at birth?

Yes

Prefer not to say

Not known

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* 4. What is your sexual orientation?

Pansexual

Not known

Lesbian / Gay woman

Bisexual

Heterosexual

Prefer not to say

Gay man

Asexual

Prefer to self-describe

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* 5. What is your ethnic group or background (choose one only)?

White - English/Welsh/Scottish/Northern Irish/British

White - Irish

White - Gypsy or Irish Traveller

Mixed/multiple - white and Black Caribbean

Mixed/multiple - white Black African

Mixed/multiple - white and Asian

Asian/British Asian - Indian

Asian/British Asian - Pakistani

Asian/British Asian - Bangladeshi

Asian/British Asian - Chinese

Black African

Black Caribbean

Black British

Any other ethnic group or background, please describe

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* 6. What is your religion or belief?

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

No religion

Prefer not to say

Other religion (please specify)

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* 7. Do you have a disability?

A disability is defined as a physical or mental impairment that has a substantial and long-term adverse effect on your ability to carry out normal day-to-day activities. (Select all that apply to you.)

Yes, physical impairment e.g. mobility difficulties

Yes, sensory impairment e.g. hearing or sight

Yes, learning difficulties e.g. dyslexia and dyspraxia

Yes, mental health conditions e.g. depression or obsessive compulsive disorders

Yes, genetic and progressive conditions e.g. motor neurone disease or muscular dystrophy

Yes, conditions characterised by a number of cumulative effects e.g. pain or fatigue

Yes, hidden impairments e.g. asthma or diabetes

Yes, history of impairment e.g. no longer disabled but met the definition in the past.

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* 8. Do you have any of the long terms conditions listed below? (Select all that apply)

Infectious diseases e.g. parasitic disease

Cancer and/or benign growths e.g. tumours, cysts

Conditions of blood and related organs e.g. anaemia, haemophilia.

Diabetes, other endocrine and/or metabolic conditions e.g. hyperglycaemia, hypothyroidism

Mental, behavioural and/or neurodevelopmental conditions e.g depression, learning disabilities

Nervous system conditions e.g. epilepsy, migraine

Eye complaints e.g. cataracts, poor sight, blindness

Ear complaints e.g. deafness, tinnitus, Meniere’s disease, balance problems

Heart and/or circulatory conditions e.g. stroke, thrombosis, heart attack, angina, hypertension

Respiratory system conditions e.g. COPD, bronchitis, emphysema, asthma

Digestive system conditions e.g stomach ulcer, abdominal hernia, digestive or bowel complaints

Skin complaints

Conditions of the musculoskeletal system e.g. arthritis, rheumatism, fibrositis, slipped disc

Conditions of the genitourinary system e.g. kidney, urinary tract, prostate, hysterectomy.

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* 9. Are you a carer?

A carer is anyone, including children and adults, who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support. The care they give is unpaid.

Yes

Prefer not to say

Not sure

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* 10. Are you a patient?
By this we mean that you either currently have a health or care need, or you have had a health or care need within the last six months. This can include a need that you have not had treatment for or not sought support for, or that you have self-managed, as well as needs that you have received care or support for.

Yes

Prefer not to say

Not sure

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* 11. Within the last six months, have you at any time been (Select all that apply)

Self-managing a condition

Seeking healthcare or social care

Receiving healthcare or social care

Awaiting healthcare or social care

Using a prescribed medication?

Not sure

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* 12. Where do you live?
To view the English regions on a map please visit: https://en.wikipedia.org/wiki/Regions_of_England#Regions_as_areas_of_administration

East Midlands

East of England

London

North East

North West

South East

South West

West Midlands

Yorkshire and Humberside

Wales

Northern Ireland

Scotland

Outside the UK

Thank you for taking the time to complete this survey. Don't forget to click done to ensure we have your answers.

To see a list of benefits for our members or view further opportunities to take part in our work, please visit our website:
www.patients-association.org.uk

Patients Association member anonymous demographic questionnaire

Question Title

* 1. What is your age?

Question Title

* 2. What gender do you identify as?

Question Title

* 3. Is your gender identity the same as the sex you were assigned at birth?

Question Title

* 4. What is your sexual orientation?

Question Title

* 5. What is your ethnic group or background (choose one only)?

Question Title

* 6. What is your religion or belief?

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* 7. Do you have a disability? A disability is defined as a physical or mental impairment that has a substantial and long-term adverse effect on your ability to carry out normal day-to-day activities. (Select all that apply to you.)

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* 8. Do you have any of the long terms conditions listed below? (Select all that apply)

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* 9. Are you a carer? A carer is anyone, including children and adults, who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support. The care they give is unpaid.

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* 11. Within the last six months, have you at any time been (Select all that apply)

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* 12. Where do you live?To view the English regions on a map please visit: https://en.wikipedia.org/wiki/Regions_of_England#Regions_as_areas_of_administration

* 7. Do you have a disability?

A disability is defined as a physical or mental impairment that has a substantial and long-term adverse effect on your ability to carry out normal day-to-day activities. (Select all that apply to you.)

* 9. Are you a carer?

A carer is anyone, including children and adults, who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support. The care they give is unpaid.

* 12. Where do you live?
To view the English regions on a map please visit: https://en.wikipedia.org/wiki/Regions_of_England#Regions_as_areas_of_administration