Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Gender-Affirming Care Medical History Form
Legal Name and Affirmed Name
Preferred Pronouns
Gender Identity
- Woman
- Man
- Nonbinary
- Self-describe in notes
- Prefer not to answer
Sex Assigned at Birth
- Female
- Male
- Intersex
- Prefer not to answer
Current Gender-Affirming Medications
| Medication | Dose | How often |
|---|---|---|
Previous Hormone Therapy History
Gender-Affirming Surgeries Completed
Transition Timeline and Goals
Mental Health Support
Reproductive Health Considerations
Gender-Affirming Care Medical History Form template from formisoft.com. formisoft.com/intake-templates/transgender-care-medical-history