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Patient Intake

Identifying a transgender patient is easiest if intake forms have a place for transgender patients to safely and confidentially identify themselves to the physician and office staff, and the staff is trained to handle the information respectfully.

The ideal patient intake form has both a "gender question" and an "assigned-sex-at-birth question" such as those shown below, and an optional "preferred pronoun" question. Asking both a gender and a sex question instead of just one (either sex or gender), and offering many choices, allows for specific disclosure of a person's history and also validates their current gender identity. Many trans people do not currently identify as transgender or transsexual for a variety of reasons. Some believe it is part of their past and not a present identification, others may not identify with "trans" terms due to cultural beliefs, social networks, or linguistic norms in various geographic areas.

1. What is your current gender identity? (Check and/or circle ALL that apply)

  • ☐ Male
  • ☐ Female
  • ☐ Transgender Male/Transman/FTM
  • ☐ Transgender Female/Transwoman/MTF
  • ☐ Genderqueer
  • ☐ Additional category (please specify): ________________________________
  • ☐ Decline to answer

2. What sex were you assigned at birth? (Check one)

  • ☐ Male
  • ☐ Female
  • ☐ Decline to answer

3. What pronouns do you prefer?_______________________

Transgender patients may reveal themselves to the physician only in the examination room, and then only because they are forced to do so because of their medical history. Physicians will not always be able to recognize a transgender patient without their self-disclosure, but in some cases a physician may discover during an examination that a patient's body does not conform to their self-declared sex, or to the sex the physician expected to find.

Even if surprised, always remain calm and respectful of the person's body and self-declared identity. Patients may not return for follow-up care if they do not feel respected or safe.

Assess patients for immediate health needs, and address illness or medical problems as needed. Verify allergies, past medical history, specialists being seen, chronic and episodic medication usage, including any cross-sex hormone medication and its source (prescription, "street" dealers, sharing with others, etc.), duration of use, any complications. Family history, with special attention to cardiovascular disease, diabetes, and cancer, especially of the breast, prostate, or reproductive organs. Psychosocial issues that may be addressed in an initial exam are discussed in the General Prevention and Screening Section. Review health care maintenance, including immunizations, TB screening, safety and safer sex counseling.