HRT (Hormone Replacement Therapy) Review Form

What is the name of your HRT? *

Why do you take HRT? *

If other reason, please expand *

Do you know how HRT works? *

Yes No

How old were you when you started taking HRT? *

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 *

Are you happy to remain on HRT? *

Yes No

Would you like to discuss changing/stopping HRT? *

Yes No

Please record your blood pressure in format xx/xx (Blood pressure monitors are readily available to purchase and provide satisfactory readings. If this is not possible, please contact reception to book an appointment for a BP check). Your HRT cannot be issued otherwise. *

Please record your weight (in kgs) *

Please record your height (in cms) *

Do you smoke? *

Smoker

Exsmoker

Non smoker

If yes, how many do you smoke/day? *

Have your parents or siblings had heart disease or stroke under the age of 45 years?

Yes No

Have you had a DVT (deep vein thrombosis)? *

Yes No

Have you had a PE (pulmonary embolus)? *

Yes No

Do you have any blood clotting illnesses or abnormalities? *

Yes No

Do you have parents, siblings or children who have had a blood clot? *

Yes No

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? *

Yes No

Do you have diabetes? *

Yes No

Do you have a family history of breast cancer under the age of 50 years? *

Yes No

Have you had a hysterectomy? *

Yes No

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? *

Yes No

If you have a Mirena coil as part of progestogen HRT, when was it inserted? (should be within 5 years) If you do not have one, please write - N/A

Do you know that menopausal symptoms can be reduced by regular exercise and by being the correct weight for your height? *

Yes No

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? *

Yes No

Are you experiencing any irregular bleeding or a change in vaginal bleeding on HRT? *

Yes No

Are you up to date with your cervical screening (smear) if you have a cervix? *

Yes No

Are you up to date with breast screening? *

Yes No

Are you on any weight loss medications/injections prescribed privately or otherwise? If yes, please see the "Weight Loss Medications and link with HRT/Contraceptive Pill" section on our website. If no, no further action required. *

Yes No

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 *

I confirm that the information provided is accurate to the best of my knowledge

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