HRT Review

Section

HRT Review

If you are unsure and you want the same one as last time, simply write ‘same’.
Are you aware that HRT does not provide contraception? *

For more information on contraception for over 40’s, please visit: Patient.Info – Contraception for the Mature Woman

Have you started taking any new regular medications, either prescribed or over the counter, since we last prescribed HRT for you? *
Have you been diagnosed with any new medical conditions since we last prescribed HRT for you? *
Do you suffer from severe headaches or migraines? *
Have you yourself ever had a blood clot in the leg (DVT – deep vein thrombosis) or a blood clot in the lung (PE – pulmonary embolism)? *
Have any of your family members ever had a blood clot in the leg (DVT – deep vein thrombosis) or a blood clot in the lung (PE – pulmonary embolism)? *
Have you ever been diagnosed with breast cancer? *
Have any of your family members ever been diagnosed with breast cancer? *
What is your smoking status? *
Are you up to date with your cervical screening (smear test)? *

To safely prescribe HRT it is important we have a record of a recent blood pressure reading from you. Please provide a recent reading in the box below, if you are unable to check your blood pressure yourself you will need to get this done either at a local chemist or by booking an appointment at the practice.

Systolic “Higher” / Diastolic “Lower”
Have you had any unusual bleeding? *
Have you had a hysterectomy? *
Do you have a Mirena coil in place? *
If aged over 50, are you up to date with your breast screening (mammogram)? *
Are you having any problems with your current HRT that you would like to discuss with us? *

If there are no concerns from the clinician, your prescription will available for you to collect from your nominated pharmacy up to 5 working days from submission of this form.

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