Your Surgery Name Goes Here

This questionnaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act.

Please indicate your ethnic origin. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions.

Choose ONE section from A to E, and then tick ONE box to indicate your background.

Patient Ethnic Origin Questionnaire

Title:	Mr Mrs Miss Ms
Forename(s):
Surname:
Date of Birth:
Email Address:
A: White
British
Irish
Any other white background please write here:
B: Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background please write here:
C: Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background please write here:
D: Black or Black British
Caribbean
African
White and Asian
Any other black background please write here:
E: Chinese or other ethnic group
Chinese
Any other please write here: