* 1. Specialty

* 2. Doctor/Specialist's Name

* 3. In terms of sensitivity to your sexual orientation or gender identity, please rate your experience from 1 (lowest) to 5 (highest) with... Doctor or Specialist.

* 4. In terms of sensitivity to your sexual orientation or gender identity, please rate your experience from 1 (lowest) to 5 (highest) with... Other clinical staff (e.g. nurse).

* 5. In terms of sensitivity to your sexual orientation or gender identity, please rate your experience from 1 (lowest) to 5 (highest) with... Front desk/administrative staff.

* 6. Overall how satisfied were you with the quality of the doctor’s care? 1 being not satisfied and 5 being extremely satisfied.

* 7. Please provide some details about your experience.

* 8. Would you recommend this specialist to a friend?

* 9. What is your sexual orientation

* 10. Do you identify as transgender or gender non-conforming?

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