PPG Form Please complete our Patient Participation Group Form below: Title Mr Mrs Miss Ms Dr Other Date of Birth First Name Surname Address Postcode Email Address Mobile Number Home Telephone Number Are you a Carer of one of our Patients? Yes No Gender Male Female Your Age Choose.... Under 16 17-24 25-34 35-44 44-54 55-64 65-74 75-84 Over 84 How often do you come to the Practice? Choose.... Regularly Occasionally Very Rarely Do you have any longstanding illness, disability or infirmity? [By long standing we mean anything that has troubled you over a period of time or that is likely to affect you over a period of time.] Yes No What is your Ethnicity? Choose.... White Black or Black British Asian or Asian British Mixed Chinese Other Ethnic Group Is your accommodation? Choose.... Owner Occupied / Mortgaged Rented or Other Arrangements Which of the following best describes you? Choose.... Employed (full or part time, incl. self employed) Unemployed and looking for work At school or in full time education Unable to work due to long term illness Looking after home/family Retired Other Send
