Let’s get to know you
What is your region?
-- Select your region --
West Berkshire
Isle of Wight
Other
What is your first name?
What is your last name?
Date of birth?
-Day-
-Month-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-Year-
What is your gender?
Female
Male
Ethnic Group
--Select--
White
Asian or Asian British
Black or Black British
Mixed
Other Ethnic group
--Select--
What is your weight?
Eg.- Kg: 75, St.: 11.10
Kg
St.
Lbs
What is your height?
Eg.- Cm: 175, Ft.: 5.9
Cm
Ft./In.
How did you hear about us?
--Select--
Website & Social Media (Facebook & Twitter)
Marketing Materials (postcards, leaflets & posters)
GP / Pharmacy / Other Healthcare Professional
Outreach Team (events / bus)
Family & Friends
Used Service Before
Other
Select your GP?
--Select--
Next
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QUIZ PROGRESS
