We would like to hear from you! First Name Surname Email Address Which locality do you live within? Berwickshire Cheviot Eildon Teviot & Liddesdale Tweeddale Don't Know Do you have any particular interest in any of the topics listed below? Please tick all that apply Children & Young People Older People Cancer Services Community Services - Community health services deliver accessible NHS healthcare services to adults and children in convenient places close to their homes and, where necessary, in their homes. Planned Care - this is the name the NHS gives to health services and treatments that aren't because of a health accident or emergency. This type of care is arranged in advance and generally follows a GP referral Unscheduled Care - NHS care which cannot reasonably be foreseen or planned in advance of contact with the relevant healthcare professional, or is care which, unavoidably, is outwith the core working period of NHS Scotland Information Management & Technology Maternity Services Volunteering Pharmacy Services Mental Health Alcohol & Drugs Equality & Diversity Public Health Health Improvement Other If you selected "Other" in the above question, please specify here What is your age? Under 16 16-19 20-29 30-39 40-49 50-59 60-64 65-74 75-84 85+ Do you consider yourself to be disabled under the Equality Act 2010? A disabled person is defined under the Equality Act 2010 as someone with a 'physical or mental impairment which has a substantial and long term adverse effect on that person's ability to carry out normal day-to-day activities' Yes No Prefer Not To Say Don't Know If you answered 'Yes' to the above question, please specify which disabilities apply to you Please tick all that apply Hearing Impairment Visual Impairment Speech Impairment Mobility Impairment Physical Co-ordination Difficulties Reduced Physical Capacity Severe Disfigurement Learning Difficulties (e.g. Dyslexic) Mental Ill Health Progressive Condition(s) Other (please specify below) If you selected "Other" in the above question, please specify here What is your cultural background? For statistical purposes, all choices in this dropdown except 'Any White Background' count as 'ethnic minority' representation White Mixed Asian; Asian Scottish; Asian British Black; Black Scottish; Black British Other Ethnic Background Prefer Not To Say Please specify Please select a cultural background in the question above What is your gender identity? Female Male Non-Binary Transgender Male Transgender Female Other Prefer Not To Say Which of the following best describes your sexual orientation? Bi-Sexual Gay or Lesbian Heterosexual / Straight Other Prefer Not To Say What is your religion or belief (including non-belief)? Agnostic Atheist Bah'ai Buddhist Christian - Catholic Christian - Protestant Christian - Other Hindu Humanism Jain Jewish Muslim Pagan Sikh Rastafarian Scientologist Shinto Zoroastrian No Religion or Belief Prefer Not To Say Any Other Religion or Belief Message