HRT Review

HRT Review

Please note that you may be asked to provide your latest blood pressure reading, height and weight.

Please answer this section if you are completing the form on behalf of someone else.

About you (The patient)

Name  Required
Date of Birth  Required
Address  Required
For example, oral tablets, patch or gel.
Do you have a hormonal coil in place?  RequiredFor example, Mirena, Jaydess or Kyleena coil.
Please answer this section if you answered YES to the above question.
Do you have any problems with your hormone replacement therapy (HRT)?  RequiredFor example, any side effects you may have.
Please answer this section if you answered YES to the above question.
Do you ever miss or forget to take your hormone replacement therapy (HRT)?  Required
Does your hormone replacement therapy (HRT) control your hot flushes?  Required
Does your hormone replacement therapy (HRT) control your mood problems?  Required
Does your hormone replacement therapy (HRT) control your vaginal dryness?  Required
Are you sexually active?  Required
Do you have any pain or discomfort during intercourse?  Required
Do you have any bleeding after intercourse?  Required
Do you need contraception?  RequiredSome hormone replacement therapy (HRT) treatments may not be effective as contraceptive. In general, all women can stop contraception at the age of 55. Speak to your GP if you wish to discuss this further.
Have you had surgery to remove your womb (hysterectomy)?  Required
Please answer this section if you answered YES to the above question.
Have you had your ovaries removed?  Required
Do you have any breast symptoms that weren't there before?  RequiredFor example, a breast lump, skin changes or nipple discharge.
Have any of your parent(s) or sibling(s) been diagnosed with breast cancer?  Required
Please answer this section if you answered YES to the above question.
Have any of your parent(s) or sibling(s) ever been diagnosed with a blood clot?  RequiredFor example, a pulmonary embolism (PE) or deep vein thrombosis (DVT).
Do you get headaches or migraines?  Required
Do you get any visual symptoms, weakness or numbness associated with your headaches or migraines when they occur?  OptionalPlease answer this section if you answered YES to the above question.
Have you recently had headaches or migraines?  OptionalPlease answer this section if you answered YES to the above question.
Please answer this section if you answered YES to the above question.
When your headaches happen, do you have to take medication to make them better?  OptionalPlease answer this section if you answered YES to the above question.
Do you get any visual symptoms, weakness or numbness associated with your headaches or migraines when they occur?  OptionalPlease answer this section if you answered YES to the above question.
Over the last 2 weeks, how often have you had little interest or pleasure in doing things?  Required
Over the last 2 weeks, how often have you felt down, depressed, or hopeless?  Required
Over the last 2 weeks, how often have you felt nervous, anxious or on edge?  Required
Over the last 2 weeks, how often have you not been able to stop or control worrying?  Required

Tell us your height and weight so we can calculate your Body Mass Index (BMI). Please also provide your latest blood pressure reading.

Please indicate whether it is in kg or stone
Please indicate whether it is in cm or feet
For example: 120/80
What else would you like to tell us?
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