Focus Group Application for Fat Patients

Name *

First Name

Last Name

Race *

I identify as (select as many are applicable):

American Indian and/or Alaska Native

Asian

Black and/or African American

Middle Eastern and/or North African

Native Hawaiian and/or Other Pacific Islander

White

I prefer not to answer

Ethnicity *

I identify as (select one):

Lantinx and/or Hispanic

Not Lantinx or Hispanic

I prefer not to answer

Ability/Disability *

I identify as (select one):

having a physical disability

having a cognitive disability

having a mental health condition

able-bodied

I prefer not to answer

Transgender *

I identify as one or more of the many identities under the transgender umbrella (trans, nonbinary, gender nonconforming, agender, gender queer, intersex, and more)

Yes (if you'd like, please specify in the open box below)

No, I identify as cisgender

I prefer not to answer

Gender *

I identify as (select as many as apply):

A man

A woman

Genderfluid, genderqueer, gender nonconforming, agender, or otherwise outside the gender binary (If you'd like, please specify in the open box below)

I prefer not to answer

Size Identity *

I identify (currently) as:

Thin, mid-size, or straight-size

Small fat

Mid fat

Super fat

Infinifat

Other (enter below)

I prefer not to answer

Orientation *

I identify as (select as many as apply):

Asexual+ (asexual, aromantic, demisexual, and/or other orientations under the Asexual umbrella)

Bisexual+ (Bisexual, pansexual, and/or other orientations under the Bi+ umbrella)

Homosexual (gay and/or lesbian)

Queer

Heterosexual and/or straight

I prefer not to answer