Hormone Replacement Therapy (HRT) Review

This form should only be used for people currently prescribed HRT.

Hormone Replacement Therapy (HRT) Review

Section

Are you currently using any contraception? *
Have you had a hysterectomy? *
Do you have a MIRENA coil fitted? *
Do you have any vaginal bleeding? *
Do you bleed after having sex? *
Do you experience any of the following?
Do you experience any of the following side effects?
Do you have a history of blood clots, breast cancer or endometrial cancer? *
Do any of you close relatives (I.e. parent, sibling or offspring) have a history of blood clots, breast cancer or endometrial cancer? *
When was the last time you experienced menopausal symptoms? *
Would you like to consider reducing your HRT? *

Please provide the following information

Smoking status: *
Would you like help to quit smoking? *
Do you drink any alcohol? *

How many of each of the following do you consume in an average week?

Blood Pressure

We need to know your blood pressure to ensure your method of contraception is still safe.

If you have access to a suitable machine, please specify and give a reading below. Otherwise, we will review your information above, and get back to you to arrange a blood pressure check.

Breast screening

It is important whilst you take HRT that you regularly check your breasts. For information, please read: Breast Cancer Now - Signs and Symptoms Information

*

Cervical screening

It is important for your health that you keep up to date with your cervical screening. For more information, please visit: www.nhs.uk/conditions/cervical-screening

Please select one option: *
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