Let’s get to know you
What is your first name?
What is your last name?
Date of birth?
-Day-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-Month-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-Year-
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
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--
Not registered with a GP
Unknown
The Avenue Medical Centre
Bharani Medical Centre
Cippenham Surgery
Crosby House Surgery
Farnham Road Surgery
Farnham Road Surgery (weekes drive)
Herschel Medical Centre
Kumar Medical Centre
Langley Health Centre
Manor Park Medical Centre
The Orchard Practice
Ragstone Road Surgery
Sharma, Veena Dr.
Shreeji Medical Centre
Slough Walk-in Health Centre
The Village Medical Centre
Wexham Road Surgery
Next
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QUIZ PROGRESS
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