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Coleridge Medical Centre

Coleridge Medical Centre, Canaan Way , 01404 814447

Ethnic Origin Questionnaire

Information on ethnicity is important to us because of the need to take into account culture, religion and language in providing appropriate individual care and the need to demonstrate non-discrimination and equal outcomes. Therefore please take a few moments to answer the following questions:

Last Updated: 23/09/2020

What is your ethnic group?

Choose one section from A to F, then select the appropriate box to indicate your culture background.

White

British

Irish

Any other White background

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 or Black British

Caribbean

African

Any other Black background

Chinese or other ethnic group

Chinese

Any other ethnic group

Not Specified

Any other background

Does not wish to state

Patient Details

Forename *

Surname *

Date of Birth *

Address *

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