Surgical Readiness Evaluation Form

Today's Date(Required)

First Name(Required)

First

Last Last(Required)

Last

Gender assigned at birth(Required)

Male

Female

Affirmed/chosen name(Required)

First or First & Last

Type in your gender(Required)

Type in your sexual orientation(Required)

Your pronoun(Required)

she/her/hers

he/him/his

they/their/theirs

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone(Required)

Your email address(Required)

Date of Birth(Required)

Your Age(Required)

Relationship Status(Required)

Single

Married

Divorced

Prefer to not answer

Employment (Status/Position/Company)(Required)

Employment

Hormonal Use History(Required)

Current Hormone Prescriber (Facility/Name/Phone) or NA if none(Required)

You therapy history(Required)

Your present living situation(Required)

Current or past suicidal ideation(Required)

Psychiatric Hospitalizations(Required)

Describe your past/present substance use(Required)

Please list any mental health conditions you are or have been treated for(Required)

Please list any current physical health issues or diseases(Required)

Please list all medications you are taking (non-prescription supplements included):(Required)

Medication Name

Dosage

Frequency

You can add more items to this list by clicking on the plus (+) button.

What was the age of your first awareness of being transgender or gender variant? Please describe any feelings or memories you had:(Required)

What childhood messages did you receive about gender identification? How may they be affecting you today?(Required)

Do you recall any childhood trauma? Please describe to your comort level:(Required)

What concerns do you have about living as your preferred gender?(Required)

Describe any significant distress and/or impairment in social, occupational, or other important areas of functioning that you are presently experiencing as a result of your gender incongruence.(Required)

Do you have any past Gender-Confirming Surgeries? Please Describe:(Required)

What Gender-Confirming Surgeries you are seeking? Please Describe:(Required)

What is your plan for your surgery? Travel and Logistics? Designated care person?(Required)

What are your long-term goals as your preferred gender?(Required)

Please describe any other information about yourself that may be helpful in working toward your transitioning goals:(Required)

Thank you so much for taking the time to fill out this questionnaire. Please click Submit below.

In order to best serve you and other patients, please agree to the following:(Required)

I agree to show up to my virtual appointments on time

I agree to not use my phone for texting or social media during virtual appointments

Surgical Readiness Evaluation Form

Surgical Readiness Evalutation Form