Event Name

Time of Event

Event Location

Who are you? Who are you? I am a health professional I am a person affected by arthritis

Name

Surname

Preferred Name

Caregiver name (if under 16 years)

Email Address

Phone number

Date of Birth

Gender

NHI number

Address

What type of arthritis do you have? What type of arthritis do you have? Gout arthritis Osteoarthritis Rheumatoid Arthritis Ankylosing Spondylitis Fibromyalgia Juvenile Idiopathic Arthritis Lupus Polymyalgia Rheumatica Psoriatic arthritis Reactive arthritis Scleroderma Sjogren's Syndrome Other Not yet diagnosed

Ethnicity Ethnicity NZ European Other European Maori Samoan Cook Islands Maori Tongan Niuean Tokelauan Fijian Other Pacific Peoples Chinese Southeast Asian Indian Other Asian Middle Eastern Latin American African European (not further defined) Pacific Peoples (not further defined) Declined to answer Other

iwi

How did you hear about the event or local activity? How did you hear about the event or local activity? Arthritis New Zealand website Facebook Newspaper advert Friend or family Phonebook Arthritis educator / already a client Radio advert Workplace Google Email/ letter from Arthritis New Zealand News story or article Health provider

If you selected health provider, which type (GP, physio, nurse, rheumatologist, etc)

Role

Organisation

Do you require a certificate of attendance? Do you require a certificate of attendance? Yes No

Privacy Statement Privacy Statement Yes, I have read the privacy statement (above)

Event Name

Time of Event

Event Location

Who are you? Who are you? I am a health professional I am a person affected by arthritis

Name

Surname

Preferred Name

Caregiver name (if under 16 years)

Email Address

Phone number

Date of Birth

Gender

NHI number

Address

What type of arthritis do you have? What type of arthritis do you have? Gout arthritis Osteoarthritis Rheumatoid Arthritis Ankylosing Spondylitis Fibromyalgia Juvenile Idiopathic Arthritis Lupus Polymyalgia Rheumatica Psoriatic arthritis Reactive arthritis Scleroderma Sjogren's Syndrome Other Not yet diagnosed

Ethnicity Ethnicity NZ European Other European Maori Samoan Cook Islands Maori Tongan Niuean Tokelauan Fijian Other Pacific Peoples Chinese Southeast Asian Indian Other Asian Middle Eastern Latin American African European (not further defined) Pacific Peoples (not further defined) Declined to answer Other

iwi

How did you hear about the event or local activity? How did you hear about the event or local activity? Arthritis New Zealand website Facebook Newspaper advert Friend or family Phonebook Arthritis educator / already a client Radio advert Workplace Google Email/ letter from Arthritis New Zealand News story or article Health provider

If you selected health provider, which type (GP, physio, nurse, rheumatologist, etc)

Role

Organisation

Do you require a certificate of attendance? Do you require a certificate of attendance? Yes No

Privacy Statement Privacy Statement Yes, I have read the privacy statement (above)