Transgender History Questionnaire

Please note: Due to HIPAA constraints, it is not possible to save this form and complete later. It must be completed in a single session.

Gender Identity Information
Describe how you feel and think about your gender.
Explain how you are currently expressing your gender in your everyday life.
Describe what problems or conflicts with gender you are experiencing.
Describe any difficulty you experience between your gender and biological sex.
Do you identify with any specific gender or sexual group? Please explain.
Describe any past or present experiences with gender support organizations.
Who have you spoken to about your gender identity issues, what do they know, and how have they responded?

Medical Information
Are you currently taking medications, hormones, or supplements to induce feminine or masculine changes in your body, for example estrogen or testosterone?*
- Yes
- No
If you are taking hormones or supplements, please list name and dosage.
Is there a prescribing physician? Please list address and phone number.
If you have taken gender medications in the past and stopped, list the medications, when you took them and why you stopped.
Describe any surgery to alter gender appearance, the surgeon's name, and when the surgery was performed.
If you are currently taking any medications for a medical condition, list the medical condition and medication.

Mental Health Information
If you have seen a psychotherapist in the past, please list their name, when, and the problem at the time
If you have taken medications for mental health reasons, for example despression or anxiety, list the medications and when taken.
If you have ever been in the hospital or emergency room for mental health reasons, list when, where and the reason.
Family Information
Are you currently married?
- Yes
- No
If yes, please list your spouse's name.
If you have children, list their names and ages.
Have you previously been married?
- Yes
- No
List dates of any previous marriages.
List parents, brothers, and sisters with their ages.
Briefly describe any important impressions about your childhood family life.
Briefly describe your current relationships with each of your family members.

Military History
If you served in the military, please list which branch.
From when to when?
Discharged at what rank?
Type of Discharge?
Did you see combat? Any comments about your experience in the military.
Educational Background
Highest level of education achieved?
Are you currently a student?
- Yes
- No
Religious Background
Were you raised in a religious home?
- Yes
- No
What religious tradition was that?
Was religion a help or a hindrance to your emerging sense of self?
Do you have a religious affiliation today?
- Yes
- No
Denomination?
Do you have a spiritual practice, see yourself as a spiritual person?
- Yes
- No
Is your spirituality or religious life something you want to talk about in therapy?

Life Story
Please write a personal story about how your experience and understanding of your gender identity and sexuality has changed over the course of your life. How did you first discover that your biological sex did not fully express your inner experience of your of your gender? Was this difficult? What have you learned about yourself and how have you grown? How have you tried to resolve your gender identity issues throughout your life? What is the vision for your future as a gendered person?
Name
This field is for validation purposes and should be left unchanged.

Problem List