Answering these questions will help us take better care of you.

Your answers will be

kept confidential.
Do you think of yourself as:
1.
2.
3.
4.
5.

Lesbian, gay or homosexual

Straight or heterosexual
Bisexual
Something else, please describe____________________________________
Don't know

How would you describe yourself? (Check all that apply)

1.
2.
3.
4.
5.
6.
7.

Male
Female
Female-to-Male (FTM)/Transgender Male/Trans Man
Male-to-Female (MTF)/Transgender Female/Trans Woman
Genderqueer, neither exclusively male nor female
Additional Gender Category/(or Other), please describe ________________
Decline to Answer, please explain why ______________________________

What sex were you at birth and is on your original birth certificate? (Check one)
1. Male
2. Female
3. Decline to Answer, please explain why ______________________________