Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Transgender Hormone Therapy Intake Form
Legal Name
Chosen Name
Pronouns
Date of Birth
____ / ____ / ________
Gender Identity
- Woman
- Man
- Nonbinary
- Self-describe in notes
- Prefer not to answer
Hormone Therapy Goals
Previous Gender-Affirming Treatments
Mental Health Support
Current Medications
| Medication | Dose | How often |
|---|---|---|
Transgender Hormone Therapy Intake Form template from formisoft.com. formisoft.com/intake-templates/transgender-hormone-therapy-intake