Historical form: online submissions are unavailable in this restored copy.

1. What medical and mental health topics affecting the LGBT community are most important to you?

2. Which of the following topics interest you? Check all that apply.
Aging Alternative health care Anal health Body image for women Body image for men Cancers in men Cancers in women Chronic illness Disabled community/ accessibility Domestic violence Depression/anxiety Drugs/alcohol Emotional health Fertility and pregnancy Fitness and nutrition HIV/AIDS	Health care access Health care differences for LGBTs Hepatitis Intersex health Men's sexual health Multiple chemical sensitivities Parenting STDs and safer sex for men STDs and safer sex for women Seniors Transgender health Violence and hate crimes Women's health Youth Other

3. What site features are you likely to use? Check all that apply.

Condition information
Educational videos
E-mail newsletter about LGBT health
Health conferences and events specific to LGBTs
Links to LGBT health resources
Message boards for peer interaction about LGBT health and
wellness
Online support groups
Forum for interacting with LGBT-friendly providers
Search for LGBT-friendly providers
Wellness and prevention education
Other

4. How would you rate the site in terms of usability? Choose one.

User-friendly
Mostly user-friendly but with a few confusing parts
Confusing
If you found any problems with usability, please describe as specifically as possible:

5. Other comments

Optional Fields (for demographic purposes)

Which of the following applies to you? Check all that apply.

LGBT health care consumer
Ally of an LGBT health care consumer
LGBT-friendly health care provider
Other

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming

Gender

Age:
under 18 18-25	26-39 40-49	50-59 60-69	70+

Contact Information (Optional)