Hormone Replacement Therapy Review Form

In order to continue prescribing your HRT safely, we need to ask you a number of questions. The process of reviewing this information and re-issuing a prescription may take up to 5 working days.  You can be provided with a prescription for one month supply of your HRT if needed whilst we deal with your request, please indicate on the questionnaire if this is needed.

General information

Alternatives to HRT

HRT
Enter Email
Please use format day/month/year e.g. 12/05/1979

Your Height and Weight

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

HRT Review

HRT Type
Are you happy with your current HRT? *
Have you considered reducing or stopping your HRT? *
Have your symptoms improved with HRT?
Would you like a nurse to call you to discuss your HRT?
Are you still having periods?
Do you have a Mirena coil fitted?
Have you had a hysterectomy?
Are you on contraception?
Are you sexually active?
Do you feel safe in your relationship?
e.g. 120/70
Smoking status *
Do you experience any of the following menopausal symptoms?
Do you experience any of the following side effects from your HRT?
Are these side effects acceptable to you?
Do you have any personal history of the following?
Do you have any family history of the following?
Are you up to date with your mammogram?
Are you up to date with your cervical smear?
Please tick the following if they apply

Privacy Policy

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.

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