HRT review form

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

Which type of HRT do you use? *

Oral (tablets)

Patch

Gel

0ral and topical

Have you read the HRT patient information leaflet? *

Yes No

Weight (Needed to proceed with HRT process) *

Height (Needed to proceed with HRT process) *

Blood Pressure (Needed to proceed with HRT process) *

Do you smoke? (If yes, please tell us the number you smoke a day) *

Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?

Deep vein thrombosis (a blood clot in the veins of the leg)

Pulmonary embolism (a blood clot in the lungs)

Stroke or cerebro-vascular disease

Heart disease

Have you been diagnosed with or experienced any of the following conditions in the past 12 months?

High blood pressure

Gallbladder disease including gallstones

Migraines

Breast cancer

Have you had a hysterectomy? (surgical removal of the womb) *

Do you suffer from migraines ? *

Yes No

Do you still experience bleeding or periods on your HRT? *

Yes No

Are any of the following menopausal symptoms not controlled by your HRT?

Flushing

Mood

Vaginal dryness

Does your HRT medication cause any side effects? *

Yes No

Do you require contraception? *

Yes No

Are you interested in reducing or stopping your HRT? *

Yes No

Further Information