What is the name of your HRT?
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If other reason, please expand
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Do you know how HRT works?
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How old were you when you started taking HRT?
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How long have you been on HRT? Are you aware that there are increased risks after 10years of HRT use? https://assets.publishing.service.gov.uk/media/5d680409e5274a1711fbe65a/Table1.pdf
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Are you happy to remain on HRT?
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Would you like to discuss changing/stopping HRT?
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Please record your blood pressure in format xx/xx(Blood pressure can be checked at your local pharmacy. Blood pressure monitors are also readily available to purchase and provide satisfactory readings)
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Please record your weight (in kgs)
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Please record your height (in cms)
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If yes, how many do you smoke/day?
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Have your parents or siblings had heart disease or stroke under the age of 45 years?
Have you had a DVT (deep vein thrombosis)?
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Have you had a PE (pulmonary embolus)?
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Do you have any blood clotting illnesses or abnormalities?
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Do you have parents, siblings or children who have had a blood clot?
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Do you understand that, rarely, HRT can cause a blood clot and that symptoms of a blood clot are calf pain and swelling, sharp chest pains, shortness or breath and coughing up blood?
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Do you have a family history of breast cancer under the age of 50 years?
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Have you had a hysterectomy?
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Are you aware of the importance of taking progestogen as part of your HRT if you have not had a hysterectomy? This can be in the form of progestogen in a patch, tablet or as a Mirena coil?
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If you have a Mirena coil as part of progestogen HRT, when was it inserted?
Do you know that menopausal symptoms can be reduced by regular exercise and by being the correct weight for your height?
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Do you understand that you should tell a healthcare professional that you are on HRT if you need to have an operation or have a period of prolonged immobilisation, e.g. leg in plaster?
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Do you understand that irregular vaginal bleeding on HRT should be reported to a healthcare professional?
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Are you up to date with your cervical screening (smear) if you have a cervix?
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Are you up to date with breast screening?
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Your health and safety are important to us and we need to ensure that we have sufficient information to complete this review. If at any time you have concerns about your HRT then please book a nurse or GP appointment
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