HRT Questionnaire

If you have been advised to submit a HRT review, please use this form.

HRT Questionnaire

Personal Details:

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

HRT Questionnaire

Have you had any unusual bleeding?
Are you taking HRT?
Do you use contraception?
Are you taking any other medications?

Are you bothered by any of the following?

Hot flushes:
Night sweats:
Loss of interest in sex:
Headaches:
Joint/muscle pains:
Irritability
Mood changes:
Difficulty in sleeping:
Irregular bleeding:
Vaginal dryness:

Smear and Mammogram Information

The result was:
Have you had a mammogram?

Pregnancy Information

Have you had any of the following?
Please upload any relevant evidence in relation to this HRT Questionnaire.
Maximum upload size: 67.11MB