LGBT Intake Form
Gay, Lesbian, Bisexual and Transgender Health
Sample of a culturally competent intake form
LGBTÂ 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)