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Ethnicity Questionnaire

We have been asked by the Government to record the ethnic origin of all new patients as this can affect certain health screening programmes and treatments. In addition, we have also been asked to record the first language of our patients. We would therefore appreciate you completing the following:

How would you describe your ethnic origin?

White:

British

Irish

Other

Mixed:

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background

Asian or Asian British

Indian

Pakistani

Bangladeshi

Any other Asian background

Black of Black British

Caribbean

African

Any other Black background

Other ethnic groups

Chinese

Any other ethnic group

First language

Also for audit purposes are you a dependant of a current serving member of the British Armed Forces?

Yes

No

Are you a military veteran?

Yes

No

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