NHS patient survey

If you have answered yes, please indicate the type of impairment which applies to you. If your experience more than one type of impairment, please tick all the types that apply. If your disability does not fit any of these types, please mark Other and specify.

Physical/mobility impairment, such as a difficulty using your arms or mobility issues which require you to use a wheelchair or crutches

Visual impairment, such as being blind or having a serious visual impairment

Hearing impairment, such as being deaf or having a serious hearing impairment

Mental health condition, such as depression or schizophrenia

Learning disability/difficulty, such as Down’s syndrome or dyslexia or a cognitive impairment such as autistic spectrum disorder

Long-standing illness or health condition, such as cancer, HIV, diabetes, chronic heart disease or epilepsy

Other