Collection of Gender Identity on a Patient Registration Form15
| 1. What is your current gender identity? (Check and/or circle ALL that apply) |
| ☐ Male |
| ☐ Female |
| ☐ Transgender male/Trans man |
| ☐ Transgender female/Trans woman |
| ☐ Genderqueer/Gender nonconforming |
| ☐ Additional identity (fill in) ______________________ |
| ☐ Decline to answer |
| 2. What sex were you assigned at birth? (Check one) |
| ☐ Male |
| ☐ Female |
| ☐ Decline to state |