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HRT questionnaire

HRT Review

Section

HRT Review

Do you know the name of the hormone replacement therapy (HRT) that you want?
Have you started taking any new regular medications or health supplements recently? *
Please include any over-the-counter supplements or medications.
Have you been diagnosed with any new health conditions since we last issued your HRT? *
These could be any conditions, but in particular: any breast or ovarian conditions, blood clots or a clotting disorder, cancer, heart disease, liver disease, migraines or diabetes.
Is HRT helping your symptoms?
Are you having any side effects or problems with your current HRT that you would like to discuss with us? *
Do you suffer from severe headaches or migraines? *
Do you have any vaginal dryness or discomfort?
If aged over 50, are you up to date with your breast screening (mammogram)? *
A mammogram is a type of X-ray that looks for breast cancer. You should be invited to have a mammogram every 3 years between the ages of 50 and 71 unless you have been told otherwise by a healthcare professional.
Are you up to date with your cervical screening (smear test)? *
Unless you have been told otherwise by a healthcare professional, you should be invited to have a smear test every 3 years between the ages of 25 and 49, every 5 years from age 50 to 64 and then over 65 if one of your last 3 smear tests was abnormal.
Have you ever been diagnosed with breast cancer? *
Do you have a family history of breast cancer? *
Have you had any new or unexpected vaginal bleeding/spotting? *
Such as after sex, between periods or after 12 months of not having a period.
Have you had a hysterectomy? *
A hysterectomy is where you’ve had surgery to remove your womb (uterus).
Are you currently using contraception?
Please note, HRT does not act as contraception.
Do you require advice about contraception?
What is your smoking status? *
How many cigarettes do you smoke in a day?
How many cigarettes did you smoke in a day?
Are you able to provide a blood pressure reading?
As part of the review of your HRT we need an up-to-date blood pressure reading.

Blood Pressure

Before you take your blood pressure reading:

  • Sit down comfortably for 5 minutes.
  • Wear loose-fitting clothing.
  • Make sure your arm is around the same level as your heart.
  • Make sure your arm is relaxed.

When taking your blood pressure:

  • Put the cuff on following the instructions that came with your blood pressure monitor.
  • Keep still and silent.

Other tips:

  • Take at least three readings, each two minutes apart.
  • Your first reading may be much higher than the next readings. If this is the case, keep taking readings until they level out and stop falling. Use this as your reading.

Please seek urgent medical attention if you develop any of the following:

  • Blood pressure is 170/115 or above (despite repeating it at least 2 times).
  • Chest pain.
  • Changes in vision.
  • Confusion.
  • Severe headache.

For more tips or to learn more, visit the British Heart Foundation website.

The higher number.
The lower number.

Height and Weight

Are you able to provide a weight and height reading?
eg. 60.6
eg. 1.75
Are you considering stopping your HRT?
Confirmation *
Confirmation *