Masculine Mental & Sexual Health Wellness, Questionnaire
This questionnaire will be used to collect information about masculine identified individuals on mental and sexual health. This questionnaire will take you 30-45 minutes to complete and we hope that you will allot the necessary time to answer each question fully. This questionnaire is divided by sections. 

"To Qualify for this questionnaire you must be masculine identified. This includes intersex, transgender, GNC and cis individuals who identify as masculine of center." 

                                                 *Please complete this questionnaire in your fullest capacity*

The purpose of this questionnaire is to:
1. Confirm the permission and origin of data
2. Educate healthcare providers and community (sexual health, mental health, wellness) workers
3. Collect quantitative data representative of our community
4. Confirm general values and principles
5. Provide control of our care

This questionnaire builds off the feedback and brilliance shared through community. We hope to confidentially  
capture all your ideas in the best possible ways for appropriate services, treatment and care. Please fill out this questionnaire to continue to help the services grow.  

As a reminder, this questionnaire will take you 30- 45 minutes to complete, and we hope that you will allot the necessary time to answer each question fully. Please complete this questionnaire as best you can. If you don't feel comfortable with some of the questions state N/A. Please do not leave any answers blank.
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Email *
Geographic Information
ALL QUESTIONS WITH THE * ARE REQUIRED

KEY:
GNC=GENDER NON-CONFORM
MASC=MASCULINE
TRANS=TRANSGENDER
TRANS MASC=TRANSMASCULINE OR PERTAINING TO TRANSMEN
TRANS FEMME=TRANSFEMININE OR PERTAINING TO TRANSWOMEN
PRE-OP=PRE OPERATION
POST OP=POST OPERATION
GAHT=GENDER AFFIRMING HORMONE THERAPY
N/M T=NON MEDICAL TRANS
CIS= CURRENT GENDER IDENTITY CORRESPONDS WITH GENDER ASSIGNED AT BIRTH
CIS MASC=MASCULINE IDENTIFIED INDIVIDUAL WHOSE CURRENT GENDER IDENTITY CORRESPONDS WITH BIRTH ASSIGNMENT
MASC FEMME=(L.B.G.Q.A) MASCULINE OF CENTER IDENTIFIED  FEMALE WHOM WAS ASSIGNED FEMALE AT BIRTH
I=INTERSEX
1. AGE RANGE *
2. SEX *
3. GENDER IDENTITY *
4. SEXUAL ORIENTATION *
5. EMPLOYED
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6. EDUCATION
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7. MEDICAL INSURANCE
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8. HOUSING *
QUESTIONS 9-20 ARE STRICTLY FOR INDIVIDUALS AFAB, some Intersex
IF YOU AREN'T A FEMALE ASSIGNED AT BIRTH PLEASE SKIP TO QUESTIONS . (place N/A on unapplied sections)
9. DO YOU STILL HAVE A MENSTRUAL CYCLE? (if you answer yes move to next question. If no skip next question 11) *
10. HOW WOULD YOU DESCRIBE YOUR MENSTRAL CYCLE?
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11. IF OVER AGE 40, HAVE YOU EVER HAD A MAMMOGRAM? *
12. IF UNDER AGE 40, HAVE YOU EVER HAD A MAMMOGRAM? *
13. HAVE YOU EVER HAD A PAP SMEAR? *
14.Check those that apply *
15. ARE YOU COMFORTABLE HAVING A PAP SMEAR PERFORMED?
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16.ARE YOU COMFORTABLE SEEING AN OB/GYN?
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17. WHEN WAS YOUR LAST PAP SMEAR? *
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18. ARE YOU SEXUALLY ACTIVE WITH PARTNERS WHOM PRODUCE SPERM? (Not all sexual partners are the same)
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19. Are you currently  on BIRTH CONTROL? *
20. HAVE YOU PREVIOUSLY BIRTHED CHILDREN OR DO YOU WANT TO IN THE FUTURE?
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IF YOU HAVE PREVIOUSLY BIRTHED CHILDREN PLEASE DETAIL CONCEPTION AND DELIVERY EXPERIENCE BELOW
QUESTIONS 21-32 ARE STRICTLY FOR INDIVIDUALS AMAB an or Intersex
IF YOU AREN'T A MALE ASSIGNED AT BIRTH PLEASE GO BACK TO QUESTION 8-18 (place N/A on unapplied sections)
21. Have you completed a colonoscopy or cologuard? *
22. Have you ever been screened for prostate cancer?  *
23. Have you ever had cholesterol checked in the past year?  *
24.  Do you use Tobacco? *
25. Do you have any second hand smoke exposure? *
26, Do you use recreational drugs (marijuana) or Illicit drugs? *
26. Do you have difficulty interacting socially? *
27. Do you need to urinate every 1-2 hours? *
28. How many times at night do you wake up to urinate? *
29. Do you have history of low testosterone?  *
30. Do you get morning erections regularly? *
31. Do you use or have you used medications for erectile dysfunction? *
32. Have you ever had issues with fertility? *
HEALTH & WELLNESS SERVICES
THESE NEXT QUESTIONS ARE STRICTLY TO OBTAIN INFORMATION FOR BETTER SERVICES
33. DO YOU HAVE AN HEALTH CARE PROVIDER (HCP) ? (primary care, mental health, endocrinologist, etc)
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34. ARE YOU COMFORTABLE SEEING YOUR HEALTHCARE PROVIDER?
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35. DOES YOUR HCP LISTEN AND ADDRESS YOUR CONCERNS?
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36. DOES YOUR HCP SEEM EDUCATED AND WELL INFORMED ABOUT TRANS/GNC/NB/MASC or MALE HEALTHCARE?
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37, IF ON HORMONES, DOES YOUR HCP FOLLOW AN INFORMED CONSENT MODEL?
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38. WHEN WAS YOUR LAST MEDICAL VISIT?
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39. HAVE YOU EVER BEEN TESTED FOR STIS (SEXUALLY TRANSMITTED INFECTIONS)?
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40. IN THE LAST 60 DAYS HAVE YOU BEEN TOLD BY A PARTNER THAT YOU HAVE BEEN EXPOSED TO AN STI?
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41. IF YES, WHAT WERE YOU EXPOSED TO?
42. WERE YOU TREATED FOR THIS STI?
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43. IF YES, WHEN DID YOU RECEIVE TREATMENT?
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44. ARE YOU CURRENTLY HAVING SYMPTOMS OF AN STI?
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45. IF YES, WHAT SYMPTOMS DO YOU HAVE?
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46 WHAT IS YOUR HIV STATUS?
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IF YOUR STATUS IS UNKNOWN OR HIV NEGATIVE PLEASE ANSWER THE NEXT SECTION, IF LIVING WITH HIV PLEASE SKIP TO QUESTION 52
47. WHEN WAS YOUR LAST HIV TEST?
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48. HAVE YOU HEARD OF PRE EXPOSURE PROPHYLAXIS (PrEP) OR TRUVADA TO PREVENT HIV INFECTION?
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49. ARE YOU CURRENTLY TAKING PrEP?
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50. HAVE YOU TAKEN PrEP WITHIN THE PAST 12 MONTHS?
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51. WOULD YOU LIKE TO ADD PrEP AS PART OF YOUR SEXUAL HEALTH PLAN?
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IF YOU ARE LIVING WITH HIV, PLEASE ANSWER THE FOLLOWING SECTION. IF NOT PLEASE ANSWER N/A OR NEVER
52. APPROXIMATELY WHEN WERE YOU DIAGNOSED WITH HIV?
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53. ARE YOU CURRENTLY TAKING MEDICATION FOR TREATMENT OF HIV?
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54. IF YES, HOW MANY DOSES HAVE YOU MISSED IN THE PAST 30 DAYS?
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55. WHEN DID YOU GET YOUR MOST RECENT HIV LABS SUCH AS CD4 AND VIRAL LOAD?
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56. WHAT WAS YOUR MOST RECENT VIRAL LOAD?
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57. IN THE LAST 12 MONTHS HAVE YOU BEEN SEXUALLY ACTIVE WITH A PARTNER(S)?
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58 IF YES, WHAT PARTS OF YOUR BODY WERE ENGAGED IN INTERCOURSE?
59. IF YES, WHAT PARTS OF YOUR PARTNERS BODY WERE ENGAGED IN INTERCOURSE?
60. DID YOU USE CONDOMS (INTERNAL OR EXTERNAL) WHEN SEXUALLY ACTIVE?
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61. ARE YOU TRANS OR GENDER NON CONFORMING AND CURRENTLY TAKING GENDER AFFIRMING HORMONE THERAPY? (IE TESTOSTERONE OR ESTROGEN BLOCKERS)
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62. HAVE YOU HAD ANY GENDER AFFIRMING SURGERY? (IE TOP SURGERY, PHALLOPLASTY, METOIDOPLASTY)
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63. WHAT TYPE OF GENDER AFFIRMING SURGERY HAVE YOU COMPLETED?
64. ARE YOU SATISFIED WITH HOW YOUR BODY IS RESPONDING TO GAHT?
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65. WHICH HORMONES ARE YOU CURRENTLY TAKING?
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66. IF INJECTABLE, WHERE DO YOU INJECT YOUR TESTOSTERONE?
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67. IF INJECTABLE, WERE YOU TRAINED BY YOUR HCP ON HOW TO SELF INJECT?
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68. IF INJECTABLE, HOW OFTEN DO YOU INJECT YOUR TESTOSTERONE?
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69. HAVE YOU NOTICED ANY CHANGE IN MOOD OR TEMPERAMENT SINCE BEING ON TESTOSTERONE?
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70. DO YOU STILL HAVE SYMPTOMS OF "PHANTOM" MENSTRUAL CYCLES? (IE CRAMPING, PMS, FOOD CRAVINGS BUT NO BLEEDING)
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71. HAVE YOU EXPERIENCED CLITORAL GROWTH?
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72. HAVE YOU HAD FREQUENT URINARY TRACT INFECTIONS OR GENITAL IRRITATION SINCE BEING ON TESTOSTERONE?
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73. HAVE YOU HAD AN INCREASE IN BODY ODOR?
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74. HOW DID YOU FINANCE YOUR GENDER AFFRIMING SURGERY?
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75. WHO PROVIDED POST OPERATIVE CARE FOR YOU?
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76. DID YOU EXPERIENCE ANY INCREASED DEPRESSION OR REGRET IN THE IMMEDIATE POST OPERATIVE PERIOD?
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77. DID YOU EXPERIENCE ANY COMPLICATIONS THAT REQUIRED REVISION?
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78. PLEASE DETAIL ANY COMPLICATIONS AND REVISIONS REQUIRED
79. ARE YOU CONSIDERING ANY FUTURE GENDER AFFIRMING SURGERY?
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80.  WHAT FUTURE SURGICAL PROCEDURES ARE YOU CONSIDERING OR PURSUING?
81. IF NO, WHAT ARE YOUR LIMITATIONS?
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82. HAVE YOU LEGALLY CHANGED YOUR NAME?
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83. IF YES, DO YOU HAVE YOUR SOCIAL SECURITY CARD CHANGED AS WELL?
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84. HAVE YOU HAD YOUR GENDER MARKER CHANGED ON LEGAL ID? (LICENSE, PASSPORT)
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85. HAVE YOU HAD YOUR BIRTH CERTIFICATE AMENDED TO REFLECT NAME/GENDER MARKER CHANGE?
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86. DO YOU NEED ASSISTANCE WITH LEGAL NAME/GENDER MARKER CHANGES?
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87. WHAT IS YOUR RELATIONSHIP STATUS?
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88. DO YOU FEEL AS IF YOUR PARTNER IS SUPPORTIVE OR AFFIRMING OF YOUR GENDER IDENTITY?
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89. HAS YOUR PARTNERS SEXUAL ORIENTATION/IDENTITY CHANGED AS A RESULT OF YOUR GENDER IDENTITY?
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90. DO YOU FEEL AS IF YOUR PARTNER RESPECTS AND ACKNOWLEDGES YOUR MASCULINITY?
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91. DO YOU FEEL AS IF YOUR SEXUAL ORIENTATION/BEHAVIORS HAVE CHANGED WITH YOUR GENDER IDENTITY?
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IF YES, PLEASE DETAIL
A copy of your responses will be emailed to the address you provided.
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