DR SMITH & PARTNERS PATIENT QUESTIONNAIRE THIS SHORT QUESTIONNAIRE

1 ADAM SMITH (17231790) Y EL ENFOQUE LIBERAL LA
13 JULY 2018 TO ALL MEMBERS COUNCILLOR R SMITH
14 STANLEY D SMITH CONTACT INFORMATION DEPARTMENT OF FINANCE

2 ADAM SMITH THE WEALTH OF NATIONS ADAM SMITH
20 INFORME NO 8110 CASO 12562 PUBLICACIÓN WAYNE SMITH
3 PAPER TITLE YOUR TITLE JOHN SMITH AND JANE

DR MCLAREN & PARTNERS: PATIENT QUESTIONNAIRE

DR SMITH & PARTNERS: PATIENT QUESTIONNAIRE



This short questionnaire will give surgery staff some basic information about your communication support needs and ethnicity to support your health care. We would be grateful if you could complete one for each family member within/joining the Practice.


Name __________________________________________ Date of Birth (dd/mm/yy) ____________________


Do you need an interpreter or sign language support? □ Yes □ No


If you do need an interpreter, which language do you speak (please state) _______________________________


What is your ethnic group?


Chose ONE section from A to E then tick ONE box which best describes your ethnic group or background.


A. White

Scottish

English

Welsh

Northern Irish

British

Irish

Gypsy/Traveller

Polish

Any other white ethnic group (please state) ____________________________________________


B. Mixed or Multiple Ethnic Groups

Any mixed or multiple ethnic groups


C. Asian, Asian Scottish or Asian British

Pakistani, Pakistani Scottish or Pakistani British

Indian, Indian Scottish or Indian British

Bangladeshi, Bangladeshi Scottish or Bangladeshi British

Chinese, Chinese Scottish or Chinese British

Other (please state) ______________________________________________________________


D. African, Caribbean or Black

African, African Scottish or African British

Caribbean, Caribbean Scottish or Caribbean British

Black, Black Scottish or Black British

Other (please state) ______________________________________________________________


E. Other Ethnic Group

Arab

Other (please state) ______________________________________________________________




If you do not wish to give this information, please tick here □


6 Oliver Goldsmith Primary School Whole School Attendance
A JOURNEY INTO HOMELESSNESS MY STORY JESSE SMITH THE
ACT NO 42 H47– DOWNING ROGERS ENGEL FIELDS SMITH


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