Referral to WLMHT Gender Identity Clinic All sections of the form are compulsory and must be completed to ensure the referral is accepted. Date of Referral Patient Details D.O.B NHS Number Sex assigned at Birth Female Male Address Postcode Patient Telephone Patient Mobile Interpreter Required Yes No If required, what language Can patient attend clinic independently Yes No If no, please give more information GP Doctor Details GP GP Practice GP Address GP Telephone GP Fax GP E-mail Referrers Details only applicable if the referrer is not the patient s GP Referrer Referrer Address Referrer Fax Referrer Job Title Referrer Telephone Referrer E-mail
The Referrer (if the referrer is not the GP) may need to liaise with the patient s GP to obtain this information Please provide us with a detailed reason for referral Medical history including computerised printout
Please provide us with any mental health history which you are aware of, including any known substance misuse or risk history Up-to-date mental state examination Please provide us with a background family history
Any other agencies involved Any other relevant information or comments Physical Health Assessment The Referrer (if the referrer is not the GP) may need to liaise with the patient s GP to obtain this information Date of Physical Health Assessment at GP Height (metres): Waist (cm) : Blood Pressure: Polycystic ovarian syndrome Yes NO N/A NHS Number: Weight (kg): BMI: Heart Rate: Physical intersex condition Yes NO Do you? Details how many, how much, units etc. Do you smoke? Yes NO Do you drink alcohol? Yes NO Do you take recreational drugs? Yes NO
Do you have or have you had any of the following? Details if answered Yes to any of the questions Epilepsy Yes NO Pulmonary Embolus/ Deep Vein Thrombosis (Blood clot) Yes NO Heart disease or Stroke Yes NO Breast Cancer Yes NO High Blood Pressure Yes NO Diabetes (Please indicate) Yes NO Type 1 Type 2 Insulin Tablets Diet Gynaecological issues Yes NO Other Medical Conditions Yes NO Past Surgical Operations Yes NO Allergies/ Other Yes NO Does your patient s family history have any of the following? Pulmonary Embolus/Deep Vein Thrombosis/blood clots Yes NO Heart disease or Stroke Yes NO Any type of cancer? Yes NO Details if answered Yes to any of the questions Please write which area i.e. bowel, breast etc. Diabetes Yes NO Type 1 Type 2 Insulin Tablets Diet On a scale of 1 to 10 (10 being good 1 being poor) rate Your energy, Drive (your get up and go feeling) And libido (sex drive): Energy Drive Libido
Blood tests Please ensure the following blood tests are completed and a computerised printout is sent with this referral: FBC U&Es LFT/Gamma GT Serum Calcium B12 & Foliate Cholesterol Triglycerides Fasting Blood sugar TFTs SHBG FSH LH Vitamin D Prolactin Testosterone Dihydrotestosterone and Oestradiol Have you previously taken any hormones at all? If so please list below: Dose Details i.e. from Internet, GP/ Other and duration of taking. Please list any current medications (not just hormones): Dose Prescribed? If yes, by whom? Duration In common with all people who risk losing their fertility through scheduled medical treatment, people with gender dysphoria are entitled to gamete storage (sperm or egg storage) and if patient's agree at the point of referral that they want to arrange this, it would be prudent for an early referral to be made to local fertility services in order that subsequent hormone treatment is not avoidably delayed. Any additional comments (if applicable):
Please note the requirements regarding GPs commitment to hormone treatment when making the referral. The Gender Identity Clinic will recommend and advise on hormone treatment and monitoring as appropriate Referrer s Signature: Referrer s Job Title Date: Please return this form to: Referral and Funding Team WLMHT Gender Identity Clinic 179-183 Fulham Palace Road London W6 8QZ Tel: 020 8483 2801 Fax: 020 8483 2873 Email: gic.administration@nhs.net Website: www.gic.wlmht.nhs.uk