Health Disparities for LGBT patients

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What is your name and email? (If you wish to remain anonymous or use a pseudonym, please do so. Email will be used for contact after the survey if you consent to a follow up interview.)

First Name :
Last Name :
Email Address :

Are you a student?

Yes

No

What is your age?

Under 18

18-25

25+

What is your gender?

What is your sexual orientation?

Do you choose to disclose your sexual orientation and/or gender identity with your healthcare provider?

Yes

No

Depends on the provider

If you answered yes, what type of experiences have you had when disclosing your identity to your healthcare provider?

Have you experienced difficulties accessing healthcare because of your sexual orientation or gender identity?

Yes

No

If you answered yes, what type of difficulties in access to healthcare have you experienced?

Have you found healthcare providers that are accepting of your sexual orientation or gender identity?

Yes

No

Other