Gender Inclusive Medical Information

Your privacy and care matter. This document serves as a valuable resource for transgender individuals and allied healthcare providers, providing essential information to ensure affirming and competent care.

Download the Form

How to Use This Form

For Individuals:

  • Download and print the form.
  • Fill it out and take it to your healthcare provider.
  • Any time is a good time to advocate for yourself, even if you're an established patient.
  • This is just one part of the process. This should be a starting point into getting more inclusive and affirming care.

For Providers:

  • Download and print the form for patients to fill out during their intake.
  • Make it a standard part of the intake process.
  • If you use virtual intake forms, download it, make it a fillable PDF, and incorporate it into your intake forms.
  • Information provided by your clients should be used to create individualized care plans.

What's Included in the Form

  • Personal Information (Preferred Name, Gender Identity, Pronouns)
  • Anatomical Inventory
  • Sexual Activity
  • Routine Screening and Preventive Care
  • Transition History
  • Hormone Therapy Details
  • Medical Transition Goals

This form collects essential information to assist healthcare providers in delivering personalized care that respects and affirms each individual's unique identity and needs. QTP does NOT retain any information.

Why This Form is Important

This form is crucial for advocating for yourself and ensuring you receive competent and respectful healthcare. It helps provide clear communication with your healthcare providers about your gender identity and medical history.

For healthcare providers, this form is a valuable tool for understanding and respecting the unique needs of transgender individuals, ensuring they receive personalized and affirming care.

Get Started Today

Download the Gender Inclusive Medical Information Sheet and share it with your healthcare provider to ensure you receive affirming and competent care.

Download Now