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HRT questionnaire

HRT Review

Section

HRT Review

If you are unsure and you want the same one as last time, simply write ‘same’.
Are you aware that HRT does not provide contraception? *

For more information on contraception for over 40’s, please visit: Patient.Info – Contraception for the Mature Woman

Have you started taking any new regular medications, either prescribed or over the counter, since we last prescribed HRT for you? *
Have you been diagnosed with any new medical conditions since we last prescribed HRT for you? *
Do you suffer from severe headaches or migraines? *
Have you yourself ever had a blood clot in the leg (DVT – deep vein thrombosis) or a blood clot in the lung (PE – pulmonary embolism)? *
Have any of your family members ever had a blood clot in the leg (DVT – deep vein thrombosis) or a blood clot in the lung (PE – pulmonary embolism)? *
Have you ever been diagnosed with breast cancer? *
Have any of your family members ever been diagnosed with breast cancer? *
What is your smoking status? *
Are you up to date with your cervical screening (smear test)? *

To safely prescribe HRT it is important we have a record of a recent blood pressure reading from you. Please provide a recent reading in the box below, if you are unable to check your blood pressure yourself you will need to get this done either at a local chemist or by booking an appointment at the practice.

Systolic “Higher” / Diastolic “Lower”
Have you had any unusual bleeding? *
Have you had a hysterectomy? *
Do you have a Mirena coil in place? *
If aged over 50, are you up to date with your breast screening (mammogram)? *
Are you having any problems with your current HRT that you would like to discuss with us? *

If there are no concerns from the clinician, your prescription will available for you to collect from your nominated pharmacy up to 5 working days from submission of this form.

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