Transgender Hormone Therapy Intake Form
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Transgender Hormone Therapy Intake Form
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This specialized intake form is designed for healthcare providers offering gender-affirming hormone therapy to transgender and non-binary patients. It captures essential information including chosen name and pronouns, gender identity timeline, dysphoria symptoms, previous gender-affirming treatments, mental health support system, and comprehensive medical history relevant to hormone safety. The form includes informed consent elements specific to masculinizing or feminizing hormone therapy risks and expected outcomes.
The template streamlines the intake process for endocrinologists, primary care providers, and specialized gender clinics following informed consent or WPATH standards of care models. It documents contraindications, baseline vital signs, fertility preservation discussions, and support system assessment. The form helps providers ensure patients understand treatment expectations while collecting all necessary clinical data for safe hormone prescription and ongoing monitoring throughout transition care.
What's included
- Chosen name and pronouns
- Gender identity and dysphoria history
- Hormone therapy goal selection
- Mental health assessment
- Previous gender-affirming treatments
- Fertility preservation discussion
- Cardiovascular risk factors
- Informed consent documentation
- Support system evaluation
- Contraindication screening
Who uses this template
- Gender-affirming care clinics
- Endocrinology practices
- LGBTQ health centers
- Primary care providers
- Transgender health specialists
All form fields
9 fields across 3 pages. Customize any field after signing up.
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