(Main Menu – click on the 3 lines) – Peel Hall Medical Practice

Title

Please print the title you wished to be referred as.

First name *

First

Surname *

Last name

Previous surname (let us know if your have changed your name)

Date of birth *

What is your age now ? *

Which of the following options best describes how you think of yourself ? *

Woman (including trans woman)

Man (including trans man)

Non-binary

In another way (Please state)In another way (Please state)

Is your gender identity the same as the gender you were given at birth ? *

Yes

No

Which of the following options best describes how you think of yourself ? *

Gay or Lesbian

Bisexual

Heterosexual or Straight

Do not know or unsure

In another way (Please state)In another way (Please state)

Would you describe yourself as intersex ? *

Yes

No

Is English your first and main language ? *

Yes

No

Please tell us what is your main language you speak ? *

Do you need an interpreter/translator for your appointments ? *

Yes

No

If you need an interpreter/translator please tell us which language you require, please type this in the box below ?