HRT (Hormone Replacement Therapy) Review

If you have been advised by the surgery to submit a HRT (Hormone Replacement Therapy) review please use this form.

Please ensure you check your Spam/Junk email folder for any replies. An appointment/reply will be sent back to you via an email.

HRT Review - Haygarth Medical Centre

If you are human, leave this field blank.

Section

BMI

Height (in Meters): *

e.g. 1.75

Weight (in Kilograms): *

e.g. 60.6

BMI:

Please note: BMI calculator is only for patients aged 18 and over.

Blood Pressure

Systolic "Higher" *

Diastolic "Lower" *

Heart Rate: *

If you are unable to provide a blood pressure reading, please request a healthcare assistant appointment. Add in comments box “For my HRT review”.

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking? *

1-2

3-4

5-6

7-9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Review

Do you smoke? *

Current smoker

Ex smoker

Never smoked

Do you find HRT effective? *

Yes

No

Please specify: *

Are you experiencing any side effects? (e.g. Migraines) *

Yes

No

Please specify: *

Has there been any changes to your health since your last HRT check? *

Yes

No

Please specify: *

Has there been any changes to your medications since your last HRT check? *

Yes

No

Please specify: *

Do you have any vaginal dryness or discomfort? *

Yes

No

Please specify: *

Are you attending the following recommended screening programmes?

Cytology: *

Yes

No

Please give details: *

Mammography: *

Yes

No

Please give details: *

Breast awareness: *

Yes

No

Please give details: *

Do you have any concerns about vaginal bleeding? *

Yes

No

Please specify: *

Do you need contraception? *

Yes

No

Please specify: *

Please add any further comments:

*

I confirm that the information provided is accurate to the best of my knowledge

I consent to receiving an SMS response from the nurse (if required)

Submit