Let’s get to know you
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--
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
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QUIZ PROGRESS
