LGBT Intake Form

Gay, Lesbian, Bisexual and Transgender Health
Sample of a culturally competent intake form

LGBT  Patients: please print out, fill out and include the following
for all of your new clinical appointments and admissions.

Clinicians: This is not intended to be a complete patient intake instrument, but for incorporation into your existing form.

What is your gender?

Male
Female
Transgendered (check one:

MTF

FTM)

What is your relationship status?

Single
Legally married
Domestic partner relationship
Divorced / separated
Widowed
Other (please specify):___________________________________

Gender of current sexual partner(s) (circle all that apply)

Male
Female
Transgendered (please specify):________________________
Not currently sexually active with others

Gender of past sexual partner(s) (circle all that apply)

Male
Female
Transgendered (please specify):________________________
Not currently sexually active with others

Are you in a relationship with another person right now?

Yes
No

If yes, is this relationship a good one for you?

Yes
No
Not sure
Not in a relationship right now

Do you need birth control?

Yes
No

If yes, are you currently using birth control?

Yes (please specify type):________________________
No

Do you have any questions about sex or sexuality?

Yes (you may state your question here or we can talk in person)_
No

Do you or your partner(s) have any children?

Yes
No

Do any children live in your household?

Yes
No

Do you need to discuss any of the following with us? (check all that apply)

Sperm or Egg banking, in anticipation of any issues
that might arise from your treatment?

Safety concerns now or a history of physical, sexual or emotional abuse
Getting along with parents
Getting along with friends
Getting along with partner
Privacy/confidentiality
Loneliness, depression, anxiety or problems eating or sleeping
Weight, bodybuilding or eating concerns
Safer sex or sexually transmitted diseases
Pregnancy test or options for starting, ending or continuing a pregnancy
Other (please specify):________________________

(reviewed December 2009)