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Please complete this form based on the experience of the person receiving care. If you are completing the form on behalf of someone else, such as a child, family member or person you care for, please answer the questions from their perspective where possible.

If you experience any difficulties using the form below, please email us directly: hiw@gov.wales

What is Your Age?
Preferred Language
Communications Needs - Please let us know if you have any specific communication requirements.
Sex - What is your sex?

A question about gender identity will follow.

Gender Identity - Is the gender you identify with the same as your sex registered at birth?
Sexual Orientation - Which of the following best describes your sexual orientation?
Religion or Belief - What is your religion or belief?
Ethnic Group - What is your ethnic group?
Health and Disability - Do you have any physical or mental health conditions or illnesses lasting or expected to last 12 months or more?

This includes conditions that are constant or occur intermittently, such as sensory impairments, developmental conditions, or learning disabilities.

Please specify your physical or mental health conditions or illnesses, i.e.

  • Physical disability or mobility impairment
  • Sensory impairment (for example, sight loss, hearing loss, or deafness)
  • Learning disability
  • Autism
  • Mental health condition
  • Long-term health condition (for example, diabetes, epilepsy, arthritis, chronic pain)
  • Neurodivergent condition (for example, ADHD, dyslexia, dyspraxia)
  • Other (please specify)
  • Prefer not to say
Pregnancy and Maternity - Are you currently pregnant or were you pregnant at the time of the concern?