HRT Review Form

If you have been advised by the surgery to submit a HRT review please use this form. Please also make sure you attend our health care assistant for a check of your blood pressure and BMI.

We appreciate you taking the time to complete this form to help us make sure you are on the most appropriate and safest treatment.

Your Details

Firstly, let us confirm your details.

Name *

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

Date of Birth *

Phone Number

Email Address *

Do you consent to getting a text message with information about your prescription or HRT? *

Yes No

HRT Review

Please confirm the name and dosage of your current HRT. *

How long have you been on HRT? Please note the risks of HRT increase after 5 years of treatment. *

What is the main reason you are taking HRT? *

Menopausal symptoms

Early menopause (before age 45)

Personal choice

Other

Womb Protection

It is important to minimise the risk of endometrial (womb) cancer whilst you are on HRT if you have not had a hysterectomy. This can be done by using progesterone either in combined HRT (oestrogen and progesterone), using the Mirena coil or separate progesterone tablets.

Have you had a hysterectomy?

Yes No

Do you have a Mirena coil in place? If so, when was it inserted (month and year)?

If you are on a tablet form of progesterone, are you taking this as prescribed?

Yes No

Current Symptoms

It is important that we know if your HRT is working and if you have any side effects.

Irregular or new vaginal bleeding can be related to the hormones in HRT but can also be a sign of something more serious. It is very important that you make an appointment to discuss this with on of our doctors or nurses if you develop any new or irregular bleeding.

Are your menopausal symptoms controlled?

Yes

Partially

Do you have any problems with your HRT? Please let us know in the text box.

Are you having any new or irregular vaginally bleeding? *

Yes - please make an appointment to discuss this

Medical and Family History

Some conditions increase the risks associated with HRT.

Risk Awareness

Please visit this link which contains information about the risks and benefits of HRT. It is important that you review this annually as your circumstances may have changed.

http://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/risks/

I confirm I have read NHS information on HRT risks (link above) *

Yes

Final Questions

Are you happy to continue on your current HRT?

Yes No

Would you like to consider alternatives or stopping?

Yes No

Would you like an appointment with our practice nurse to discuss your HRT?

Yes No

Thank you

Thank you very much for completing this form. Your answers will be reviewed and we will be in touch if there are any issues. If you have any concerns please contact the practice.

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HRT Review Form

HRT Review Form

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