HRT Review Form

When was your last period? *

Name of HRT in use

Approximate duration of using HRT

Have you had a hysterectomy? *

Yes No

Do you currently have a Mirena coil fitted? *

Yes No

If yes, what date was your Mirena coil fitted?

Weight *

Height *

Please provide us with a recent blood pressure reading (a BP machine is located in the reception area of the Medical Centre. Or you can use a home BP machine) *

Smoking Status *

Smoker

Ex-Smoker

Non-Smoker

Are you currently taking any of the following medications?

Anti-epileptic medication

Rifampacin

St Johns Wort

Have you been experiencing side effects since you started HRT? *

Have you considered reducing or stopping your HRT? *

Yes No

Have you experienced any persistent unexpected bleeding, or increased bleeding? *

Yes No

Do you regularly self-check your breasts? *

Yes No

If applicable, are you up to date with your mammograms? *

Yes No

Do you have a history of deep vein thrombosis or pulmonary embolism? *

Yes No

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

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.

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