HRT Review – Male « St Martins Medical Centre

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Who are you submitting this request for?

What is your relation to the patient? OptionalPlease answer this section if you are completing the form on behalf of someone else.

About you (The patient)

Name

First Last

Date of Birth

DD slash MM slash YYYY

Mobile

Address

Street Address Address Line 2 City County / State / Region Postcode Country

Sex assigned at birth

Female

Male

Please tell us what type of hormone replacement therapy (HRT) you are using, including the name and dose if known.For example, oral tablets, patch or gel.

Do you have any problems with your hormone replacement therapy (HRT)?For example, any side effects you may have.

Yes

Please tell us more about these problems with your hormone replacement therapy (HRT). OptionalPlease answer this section if you answered YES to the above question.

Do you ever miss or forget to take your hormone replacement therapy (HRT)?

Yes

Does your hormone replacement therapy (HRT) control your hot flushes?

Yes

Somewhat

Does your hormone replacement therapy (HRT) control your mood problems?

Yes

Somewhat

Are you sexually active?

Yes

Do you have any pain or discomfort during intercourse?

Yes

Do you have any bleeding after intercourse?

Yes

Have any of your parent(s) or sibling(s) ever been diagnosed with a blood clot?For example, a pulmonary embolism (PE) or deep vein thrombosis (DVT).

Yes

I don't know

Do you get headaches or migraines?

Yes

Do you get any visual symptoms, weakness or numbness associated with your headaches or migraines when they occur?Please answer this section if you answered YES to the above question.

Yes Optional

No Optional

Have you recently had headaches or migraines?Please answer this section if you answered YES to the above question.

Yes Optional

No Optional

How often do you get your headache or migraines? OptionalPlease 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?Please answer this section if you answered YES to the above question.

Yes Optional

No Optional

Do you get any visual symptoms, weakness or numbness associated with your headaches or migraines when they occur?Please answer this section if you answered YES to the above question.

Yes Optional

No Optional

Over the last 2 weeks, how often have you had little interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you felt down, depressed, or hopeless?

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you felt nervous, anxious or on edge?

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you not been able to stop or control worrying?

Not at all

Several days

More than half the days

Nearly every day

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

Tell us your weightPlease indicate whether it is in kg or stone

Tell us your heightPlease indicate whether it is in cm or feet

Please provide your blood pressure reading with your systolic (upper) and diastolic (lower) valuesFor example: 120/80

Is there anything else you would like to tell us that we have not asked? OptionalWhat else would you like to tell us?

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ImportantImportant

HRT Review – Male

HRT Male Review

About you (The patient)

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

Additional Information