This is the Tavistock questions:
A. Ethnic Group (Please select the ethnic group that you most identify with from the list below):
Country of origin:
Are you a Refugee or stateless person?
First language:
Do you need an interpreter?
B. Religious Beliefs (Please tick the appropriate box)
C. Sexuality
D. Marital Status
D. Employment Status
E. What is your accommodation status? (
F. Do you smoke?
G. Are you an ex-member of British armed forces or dependent on such a person?
H. Disability Monitoring
Do you have any physical or mental health conditions lasting, or expected to last, 12 months or more?
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Yes, limited a lot ☐
No
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Yes, limited a little ☐
Prefer not to say
If you answered yes to the above then please complete the following
Yes, limited a lot Yes, limited a little No Prefer not to say
Behaviour/Emotional ☐
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Hearing ☐
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Manual dexterity ☐
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Memory or ability to concentrate, learn or understand (Learning Disabilities and Autism Spectrum Disorder) where patient was 18 or over when symptoms began ☐
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Mobility and Gross Motor ☐
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Perception of physical danger ☐
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Personal, self-care and continence ☐
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Progressive conditions and physical health (e.g. HIV, cancer, multiple sclerosis, epilepsy) ☐
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Sight ☐
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Speech ☐
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Autism Spectrum Conditions ☐
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Other (please specify): ☐
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If you have a disability do you use any assistive technology?
I. Accessible Information