Gender-Affirming Care Intake Form

1. What is the name you go by?

2. What is your legal name, if different than above?

4. What is your date of birth?

5. Name of family physician/nurse practitioner:

5a. Phone number of family physician/nurse practitioner:

6. What is your Saskatchewan Health Services Number?

7. Gender Marker on health card?

8. Phone number at which we can reach you?

8b. What is your email address?

Please complete the Consent for Electronic Communications form found here:

9. What is your mailing address?

If Other, please explain

11. Have you been prescribed hormones, recently moved and need a new provider?

12. How would you describe your gender identity?

13. How long have you felt this way? And/or how long have you been considering gender affirming hormones and/or surgery?

14. Is there anything you have already done to align with your gender identity (e.g. changing name or pronouns, changing clothing/hair style)

15. Who have you talked to about your gender identity?

16. Who are your support people?

17. What do you feel dysphoria or incongruence about in your body?

18. What are you hoping to change to feel more aligned with your gender identity?

19. What worries do you have about medical interventions?

21. Have you had any previous surgeries (e.g. tonsils, appendix)?

22. Do you take any regular medications? If yes, what are they?

23. Do you have any allergies?

Name

This field is for validation purposes and should be left unchanged.