Hormone Replacement Therapy Review Form

You will need an up to date blood pressure reading before you complete the online details. This can be easily organised using a home monitoring machine or through local pharmacies and Gyms. Please record this before you complete the application.

General information

Benefits and risks of hormone replacement therapy (HRT)

Alternatives to HRT

This form is only for patients who have already been prescribed HRT for menopause symptoms, are happy with it and would like to re-order it.

If you have been advised by the practice to submit an HRT Review Form please use this form.

A clinician will review your form and – if safe to do so – will re-prescribe your HRT medication usually for 6 months.  We’ll send you a text to let you know.  Your HRT will then be available for collection in a few days at your nominated pharmacy or from reception. 

You’ll then need to complete this review form every time you’d like us to re-prescribe HRT.

If after reviewing your form we need to have a further discussion with you before re-prescribing your HRT, we’ll text you to ask you to book a GP appointment.


HRT
Enter Email
Please use format day/month/year e.g. 12/05/1979

Your Height and Weight

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese
e.g. 120/70

HRT Review

Do you smoke? *
Have you or a close family member, ever had a blood clot? *
It is thought that the risk of developing a blood clot is 2-4 times higher than normal for women taking HRT tablets. But as the risk of menopausal women developing blood clots is usually very low, the overall risk from taking HRT tablets is still small. It is estimated that for every 1000 women taking HRT tablets for 7.5 years, fewer than 2 will develop a blood clot.
Have you or a close family member got a history of Breast Cancer?
Have you or a close family member got a history of Ovarian Cancer?
Have you ever had a heart attack or a stroke?
Do you have a first degree relative (e.g. parents, siblings or children) who has had a Heart Attack or Stroke under the age of 50?
Are you happy with your current HRT? *
Are you suffering any menopausal symptoms? *
Do you have any side effects from the HRT? *
Do you need contraception? *

Please note if you are under 55 years old you may need contraception. If you need to discuss this please arrange an appointment with a doctor or a practice nurse.

Do you check your breasts for lumps regularly? *
Are you up to date with your cervical screening? *
Are you up to date with your breast screening? *
Have you had a hysterectomy? *
IF you are on a bleed-free form of HRT, have you had any bleeding? (you should not experience bleeding after the first 3 months)?
Have you noticed any unusual or unexpected bleeding?
This might include unusual bleeding in between regular periods, bleeding after sex or bleeding 12 months after your last period?
Do you have a hormonal coil ? *
I confirm that:

Privacy Policy

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.