Download Referral to WLMHT Gender Identity Clinic

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
_ _ /_ _ /
20
_ _
Patient Details
Name
D.O.B
NHS Number
Sex assigned at
Birth
please circle:
Postcode
Address
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 Name
GP Practice
Name
GP Address
GP Telephone
GP Fax
GP E-mail
Referrers Details only applicable if the referrer is not the patient’s GP
Referrer Name
Referrer Job Title
Referrer
Address
Referrer
Telephone
Referrer Fax
Referrer E-mail
_ _ /_ _/
Female
19
_ _
Male
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 AssessmentThe Referrer (if the referrer is not the GP) may need to liaise with the patient’s GP to obtain this nformation
Date of Physical
Health Assessment
at GP
NHS Number:
Height (metres):
Weight (kg):
Waist (cm) :
BMI:
Blood Pressure:
Heart Rate:
Polycystic ovarian
syndrome
☐ Yes ☐
NO
☐
N/A
Physical intersex
condition
☐ Yes
☐
Do you?
Details how many, how much, units etc.
Do you smoke?
Do you drink alcohol?
Do you take recreational drugs?
☐ Yes
☐ Yes
☐ Yes
☐
☐
☐
NO
NO
NO
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
☐ Yes
☐ Yes
☐
☐
☐
☐ Yes
☐
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐
☐
☐
☐
Breast Cancer
High Blood Pressure
Diabetes (Please indicate)
Gynaecological issues
Other Medical Conditions
Past Surgical Operations
Allergies/ Other
NO
NO
NO
Type 1
NO
Insulin
Type 2
Tablets
Diet
NO
NO
NO
NO
Does your patient’s family history have any of the following?
Details if answered Yes to any of the
questions
Pulmonary Embolus/Deep Vein
Thrombosis/blood clots
☐ Yes
☐
NO
Heart disease or Stroke
☐ Yes
☐
NO
Please write which area i.e. bowel, breast etc.
Any type of cancer?
☐ Yes
☐
NO
Diabetes
☐ Yes
☐
NO
Type 1
Insulin
Type 2
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
1
2
3
4
5
6
7
8
9
10
Drive
1
2
3
4
5
6
7
8
9
10
Libido
1
2
3
4
5
6
7
8
9
10
Blood tests
Please ensure the following blood tests are completed and a computerised printout is sent with this
referral:
☐ FBC
☐ TFT’s
☐ U&E’s
☐ SHBG
☐ LFT/Gamma GT
☐ FSH
☐ Serum Calcium
☐ LH
☐ B12 & Foliate
☐ Vitamin D
☐ Cholesterol
☐ Prolactin
☐ Triglycerides
☐ Testosterone
☐ Fasting
☐ Dihydrotestosterone and Oestradiol
☐ Blood Sugar
Have you previously taken any hormones at all? If so please list below:
Name
Dose
Details i.e. from Internet, GP/ Other and duration of
taking.
Please list any current medications (not just hormones):
Name
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 Job Title
Referrer’s Signature:
Please return this form to: Referral and Funding Team
WLMHT Gender Identity Clinic
179-183 Fulham Palace Road
London
W6 8QZ
Tel:
Fax:
Email:
Website:
0208 483 2801
0208 483 2873
[email protected]
www.gic.wlmht.nhs.uk
Date: