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.
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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)
