Carse Medical Practice – PATIENT ETHNICITY QUESTIONNAIRE This Short

carse medical practice – patient ethnicity questionnaire this short questionnaire will give surgery staff some basic information about your

Carse Medical Practice – PATIENT ETHNICITY QUESTIONNAIRE
This short questionnaire will give surgery staff some basic
information about your communication support needs and ethnicity to
support your health care.
We should be grateful if you could complete one for each family member
within/joining the practice.
Name……………………………………………. DOB……………………
Do you need an interpreter or sign language support? Yes/No
If you do need an interpreter what language do you speak? 9NU%
Please state……………………………………………………….
What is your ethnic group?
Choose ONE section from A to E then tick ONE which best describes your
ethnic group or background.
A White
Scottish …. 9S13
English …. 9i20
Welsh …. 9i22
Northern Irish …. 9i24
British …. 9S10
Irish …. 9S11
Gypsy/Traveller …. 9i2E
Polish …. 9i2F
Any other white ethnic group, please write in ………………………………. 9S12
B Mixed or multiple ethnic groups
Any mixed or multiple ethnic groups …. 9SB
C Asian, Asian Scottish or Asian British
Pakistani, Pakistani Scottish or Pakistani British …. 9S7
Indian, Indian Scottish or Indian British …. 9S6
Bangladeshi, Bangladeshi Scottish or Bangladeshi British …. 9S8
Chinese, Chinese Scottish or Chinese British …. 9S9
Other, please write in ……………………………………………….. 9SH
D African, Caribbean or Black
African, African Scottish or African British …. 9S3
Caribbean, Caribbean Scottish or Caribbean British …. 9S2
Black, Black Scottish or Black British …. 9S41
Other, please write in………………………………………………… 9S4
E Other ethnic group
Other, please write in………………………………………………… 9SJ
F Other.
Ethnic group – patient refused …. 9SD