Gender Identity Assessment Questionnaire

As part of your care and possible referral to the Gender Identity Clinic, please complete this form prior to your appointment.

Gender Identity Assessment Questionnaire

Personal Details

What was your gender at birth?
Have you been seen in the Gender Identity Clinic previously?
Are you seeking a referral to the Gender Identity Clinic?
Do you have a preference to which clinic you would like to be seen at?
Are you self medicating with treatments/hormone therapy already?
Are you part of an LGBT group/ community?
Do you require an interpreter?
Can you attend the clinic independently?
Are you born of a multiple pregnancy e.g. Twins?
Are you an ex member of British armed forces, or dependent on such a person?
Have you made a social role transition to your preferred gender role?
Have you made an official name change?
Have you re-registered with your preferred name at your GP surgery or changed your name on legal documents e.g. passport?
Do you smoke?
Do you drink alcohol?
Do you take recreational drugs?
Systolic / Diastolic