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 The
name I choose for this survey is
Please
pick a name not already used
on
this page.
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1.
I am willing to update
this information as time goes
along
Yes
No
2.
It’s okay to publish these
experiences and comments in resources
under the anonymous name
above.
Yes
No
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My year of
birth –
My ethnicity is –
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TESTOSTERONE
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Age at which
I started taking Testosterone
I take
testosterone to –
I consider
the end result of taking testosterone
for me is –
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HABITS
& HEALTH
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Smoking or
Tobacco –
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I
used to
I
don’t smoke at all
I
do smoke
I
only smoke socially
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Drinking/
Alcohol –
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I
don’t drink alcohol at
all
I
rarely drink
I
only drink socially
I
drink every day
I
think I have a drinking
problem
Are you concerned about the amount you
drink?
No
Yes
Are you prone
to “binge” drinking?
No
Yes
Have you ever
experienced blackouts because of
drinking?
No
Yes
How many drinks
would you have in a week?
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Exercise
–
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Sedentary
(No exercise)
Mild
exercise (i.e., climb stairs, walk 3
blocks, golf)
Occasional
vigorous exercise (i.e., work or
recreation, less than 4x/week for 30
min.)
Regular
vigorous exercise (i.e., work or
recreation 4x/week for 30
minutes)
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RECREATIONAL
or STREET DRUGS
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I
never use recreational or street
drugs
I
have used recreational drugs
I
only use drugs socially
I
use drugs every weekend
I
maintain a drug habit
Have you ever given yourself street
drugs with a needle?
No
Yes
Have you ever
shared needles?
No
Yes
Do you
regularly smoke marijuana?
No
Yes
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MENTAL
HEALTH & MENTAL ILLNESS,
PHYSICAL CONDITION
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Do you have any
mental health diagnoses? (eg
depression, bipolar, schizophrenia,
etc)
No
Yes
Do you have any
physical illness/condition diagnoses?
(eg disability, or syndrome etc)
No
Yes
Is stress a
major problem for you?
No
Yes
Do you feel
depressed? or has a doctor diagnosed
you with depression?
No
Yes
Do you panic
when stressed?
No
Yes
Do you have
problems with eating or your
appetite?
No
Yes
Do you cry
frequently?
No
Yes
Have you ever
seriously thought about hurting
yourself?
No
Yes
Do you have
trouble sleeping?
No
Yes
Have you ever
been to a counselor?
No
Yes
Have you
noticed any changes in your mental
health prior to taking testosterone
compared to after taking it?
No
Yes
If so - can you
describe these?
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LIFE BEFORE
TESTOSTERONE
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How do you see
your life before transition?
What was your
identity before you started
treatment?
Before
transition - what emotion was most
common for you?
Did you ever
have an 'exit-plan' or attempt suicide
at any time?
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TRANSITION
& TREATMENT
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What is
transition to you? What does transition
mean for you?
What medical
process did you go through and what is
your hormone regime (what dose and
type) - please explain if this is not
set.
What changes
did medical treatment have on your body
- that you wanted?
What changes
did medical treatment have on your body
- that you didn't want?
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Did
testosterone or transition change your
sexuality (who you are attracted to)?
No
Yes
If it did
change, how did you feel/deal/cope with
the change of sexuality?
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HEALTH CARE
PROVIDERS
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What was the
most helpful aspect of the health care
provider's treatment for you?
For example, manner, attitude, words
used, way you were treated etc (please
give examples if you can).
What was the
worst aspect of the health care
provider's treatment for you?
For example, words used, way you were
treated etc.
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Who are the
health care professionals you saw for
help with your health needs?
(Excluding
SURGEONS or Surgical
Procedures).
Surgery questions are further down
in this survey.
There are four
spaces below to provide this
information.
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This
is an example -
I
sought the assistance of
who is an
in .
Overall, I found this doctor to be
.
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1.
I sought the
assistance of
who is an
in .
Overall, I found this doctor is
.
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2.
I sought the
assistance of
who is an
in .
Overall, I found this doctor is
.
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3.
I sought the
assistance of
who is an
in .
Overall, I found this doctor is
.
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4.
I sought the
assistance of
who is an
in .
Overall, I found this doctor is
.
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HEALTH CARE
PROVIDERS
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Have you had
any surgery? - if so - please let
us know about it.There are four spaces
below to provide this
information.
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This
is an example -
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MONTH/YEAR
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TYPE
OF SURGERY
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SURGEON
& PLACE
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THIS
DOCTOR WAS
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SURGERY
OUTCOME
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1.
YEAR
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TYPE OF
SURGERY
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SURGEON &
PLACE
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THIS DOCTOR
WAS
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SURGERY
OUTCOME
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2.
YEAR
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TYPE OF
SURGERY
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SURGEON &
PLACE
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THIS DOCTOR
WAS
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SURGERY
OUTCOME
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3.
YEAR
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TYPE OF
SURGERY
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SURGEON &
PLACE
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THIS DOCTOR
WAS
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SURGERY
OUTCOME
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4.
YEAR
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TYPE OF
SURGERY
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SURGEON &
PLACE
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THIS DOCTOR
WAS
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SURGERY
OUTCOME
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OTHER
COMMENTS
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Any final
comments about transition - about the
process - or perhaps you have some
final words of wisdom for new guys who
are thinking about starting
testosterone - or something else to
share about transition?
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Thank
you.
YOU HAVE COMPLETED THIS FORM
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Testosterone Transition Survey
