Step 1 of 40%The basicsPreferred name* First Age*GenderPlease describe how you choose to identify, for example 'female', 'non-binary' or 'no' if you prefer not to answer.Language spoken*Please selectEnglishChineseHindiBengaliAbkhazianAfarAfrikaansAkanAlbanianAmharicArabicAragoneseArmenianAssameseAvaricAvestanAymaraAzerbaijaniBambaraBashkirBasqueBelarusianBihari languagesBislamaBosnianBretonBulgarianBurmeseCatalan, ValencianChamorroChechenChichewa, Chewa, NyanjaChuvashCornishCorsicanCreeCroatianCzechDanishDivehi, Dhivehi, MaldivianDutch, FlemishDzongkhaEsperantoEstonianEweFaroeseFijianFinnishFrenchFulahGalicianGeorgianGermanGreek, Modern (1453–)GuaraniGujaratiHaitian, Haitian CreoleHausaHebrewHereroHiri MotuHungarianInterlingua (International Auxiliary Language Association)IndonesianInterlingue, OccidentalIrishIgboInupiaqIdoIcelandicItalianInuktitutJapaneseJavaneseKalaallisut, GreenlandicKannadaKanuriKashmiriKazakhCentral KhmerKikuyu, GikuyuKinyarwandaKirghiz, KyrgyzKomiKongoKoreanKurdishKuanyama, KwanyamaLatinLuxembourgish, LetzeburgeschGandaLimburgan, Limburger, LimburgishLingalaLaoLithuanianLuba-KatangaLatvianManxMacedonianMalagasyMalayMalayalamMalteseMaoriMarathiMarshalleseMongolianNauruNavajo, NavahoNorth NdebeleNepaliNdongaNorwegian BokmålNorwegian NynorskNorwegianSichuan Yi, NuosuSouth NdebeleOccitanOjibwaChurch Slavic, Old Slavonic, Church Slavonic, Old Bulgarian, Old Church SlavonicOromoOriyaOssetian, OsseticPunjabi, PanjabiPaliPersianPolishPashto, PushtoPortugueseQuechuaRomanshRundiRomanian, Moldavian, MoldovanRussianSanskritSardinianSindhiNorthern SamiSamoanSangoSerbianGaelic, Scottish GaelicShonaSinhala, SinhaleseSlovakSlovenianSomaliSouthern SothoSpanish, CastilianSundaneseSwahiliSwatiSwedishTamilTeluguTajikThaiTigrinyaTibetanTurkmenTagalogTswanaTonga (Tonga Islands)TurkishTsongaTatarTwiTahitianUighur, UyghurUkrainianUrduUzbekVendaVietnameseVolapükWalloonWelshWolofWestern FrisianXhosaYiddishYorubaZhuang, ChuangZuluCountry you were born in*Please selectAustraliaUnited KingdomChinaIndiaNew Zealand----AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsMy relationship with my GP is:* Good Average PoorMy HealthI rate my health as Good Average PoorI have...If you have one or more of these, please tick each one. heart disease arthtritis diabetes breathing problems kidney diseaseI have another condition...Number of medications per dayPlease enter a number from 1 to 100.My diet is... good average poorIn the last six months I have lost weight gained weight stayed the same weightI have lost or gained this many kgsPlease enter a number from 1 to 100.My hearing is good average poorI wear a hearing aid yes noMy vision is good average poorPhysical activitiesI can walk a short way a long way I can't walkWalking frames I don't need a frame I need a frameHiddenMobility*Describe your ability to walk. You can check more than one box if appropriate: I cannot walk unaided I can walk a short distance with a frame I can walk a long distance with a frame I can walk a short distance unaided I can walk a long distance unaidedHiddenWalking unaided*I can walk without a frame: A short distance A long distanceHiddenWalking with a frame*I can walk with a frame: A short distance A long distanceExercise*I walk or do some exercise: Daily Weekly NeverShopping*I do this much of my own shopping: All Some NoneHousework*I do this much of my own housework: All Some NoneCooking*I do this much of my own cooking: All Some NoneI have help with*Please explain what tasks or activities you have help with at home, such as cleaning or dressing.Falls*How many falls have you had in the last 6 months?EmailEmailWould you like this form to be emailed to you? YesEmailThis email address will be deleted after it has been sent. PhoneThis field is for validation purposes and should be left unchanged.
