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You’re just a few questions away from getting your medication!
Please fill this questionnaire to complete your order.
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Please enter your first name:
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Please enter your last name:
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Please enter your email:
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How old are you?
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How do you identify?
Nonbinary
Trans woman
Trans man
Cis woman
Cis man
Intersex
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What was your sex assigned at birth?
Male
Female
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Have you ever taken hormones for gender affirming care before?
Estradiol valerate
Estradiol hemihydrate
Spironolactone
Cyproterone Acetate
Phenokinon
Diane 35
Testosterone enanthate
Testosterone cypionate
None
Others
Please select at least one option.
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If you have taken other hormone therapy, please list them here:
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Which medication are you interested in?
Estradiol Gel
Spironolactone
Testosterone Enanthate
Please select at least one option.
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Describe any issues you experienced while on the medication? Please elaborate:
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Have you undergone gender affirming surgery? If so, please specify what kind, when and where was it done.
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Have you ever gotten your blood work done to see if you qualify for GAHT? If yes, you will be asked to email your results to Dima.
Yes
No
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What are your goals with hormone therapy?
TW Body changes (ex. breast growth, voice changes, body hair reduction)
TM Body changes (ex. Increased muscle, voice changes, hair growth)
Relief from gender dysmorphia
Increased sense of gender alignment
Enhanced self-esteem and confidence
Other
Please select at least one option.
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What was your latest blood pressure reading in the last 6 months?
Low
Normal
High
Very High
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Which prescription medicines are you currently on?
Anticonvulsants (e.g., Phenytoin, Carbamazepine)
Antibiotics (e.g., Rifampin)
Blood thinners (e.g., Warfarin, Heparin)
St. John's Wort
Anti-hypertensives (e.g., ACE inhibitors, Diuretics)
Insulin or oral hypoglycemics (For Diabetic Patients)
Antiretrovirals
Medications for mental health
Medications for bone health
None of the above
Please select at least one option.
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Do you have any allergies to medications or otherwise? Please specify below.
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Have you ever had or do you currently have any of the following medical conditions?
Blood clotting disorders (e.g., Deep Vein Thrombosis, Pulmonary Embolism)
Cardiovascular disease (e.g., Heart Disease, High Blood Pressure, Atherosclerosis)
Liver disease (e.g., Cirrhosis, Hepatitis)
Breast cancer
Prostate cancer
Diabetes
Hyperlipidemia (High Cholesterol Levels)
Mental health conditions (e.g., Depression, Anxiety, Mood Disorders)
Endocrine disorders (e.g., Thyroid Disease)
Kidney disease
Pregnant or lactating
An STI (HIV, Syphilis, Herpes 1 or 2, Hepatitis B or C, Chlamydia, Gonorrea, Trichomoniasis, Mycoplasma Genitalium)
Anti-osteoporosis medications
None of the above
Please select at least one option.
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Do you have any mental health conditions listed below?
Anxiety
Depression
Insomnia
Bipolar disorder
None of the above
Please select at least one option.
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If you have mental health conditions, which medications are you taking?
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Do you understand the listed expected time course of physical changes in response to GAHT?
Yes
No
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Do you understand the listed health risks of GAHT?
Yes
No
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Do you consent to receiving medication for GAHT and agree to the
T&C
and
privacy policy
of this platform?
Yes
No
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(Please note that in order to obtain a refill of the medication a tele-consult with a trans health doctor is required after 1 month)
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