HRT Review

Please only complete the following questionnaire if requested by your GP practice as part of your routine review.

This questionnaire is for a routine review of your HRT. If you are experiencing any of the following ring your GP immediately: - Painful swelling of your leg. - Weakness or numbness of an arm or leg. - Sudden problems with your speech or sight. - Difficulty breathing. - Coughing up blood. - Pains in your chest, especially if it hurts to breathe in. - Unexpected vaginal bleeding - Persistent irregular vaginal bleeding - Breast lump, persistent breast pain, or nipple changes. - Abdominal pain, discomfort or bloating - Weight loss that is not intended

Full Name(Required)

Date of Birth(Required)

Phone Number(Required)

Email address(Required)

1. When was your last period?(Required)

2. Have you had a hysterectomy(Required)

Yes

3. Have you had a Mirena coil (intrauterine system, IUS) fitted?(Required)

Yes

4. If yes, what date was your Mirena coil fitted?(Required)

5. What is your current weight?(Required)

6. What is your current height?(Required)

7. What is your current heart rate/pulse rate?

8. What is your systolic blood pressure? (The larger number)

9. What is your diastolic blood pressure? (The smaller number)

10. Please enter your current GREEN SCORE: (please see the link below)(Required)

https://jeanhailes.org.au/contents/documents/Health_Professionals/Menopause_symptom_scale_Greene_Climacteric.pdf

11. Have you been experiencing side effect since you started HRT?(Required)

Yes

Unsure

12. If yes, please provide details of the side affects you have been experiencing:

13. Have you considered reducing or stopping your HRT?(Required)

Yes

14. Have you experienced any persistent unexpected bleeding, or increased bleeding?(Required)

Yes

15. Do you regularly self-check your breasts?(Required)

Yes

16. If applicable, are you up to date with your mammograms?(Required)

Yes

17. Have you ever had any blood clots? (e.g. Deep Vein Thrombosis or Pulmonary Embolism)(Required)

Yes

18. Have you ever had a heart attack or stroke?(Required)

Yes

19. Have you ever had breast cancer or endometrial cancer?(Required)

Yes

20. Have you ever had liver or gallbladder disease?(Required)

Yes

21. Do you have a family history of any of the following? Please select any that apply(Required)

Blood Clots (e.g. Deep Vein Thrombosis or Pulmonary Embolism)

Breast Cancer

Endometrial Cancer

Heart Attack

Stroke

None of the above

22. Are you using contraception(Required)

No, because I am over 50 and my last period was over 1 year ago.

No, because I am under 50 and my last period was over 2 years ago.

No, because I am over 55.

Yes

23. If yes, please provide details of your current contraception:

24. I have the following questions that I would like to raise about HRT with my Nurse or Doctor.

Please see the following links for further information on the HRT that you may find useful:

Menopause Matters - https://www.menopausematters.co.uk/

NHS - https://www.nhs.uk/conditions/menopause/

Menopause - https://patient.info/womens-health/menopause

HRT - https://patient.info/womens-health/menopause/hormone-replacement-therapy-hrt

Alternatives to HRT - https://patient.info/womens-health/menopause/alternatives-to-hrt

Please see the following links for further information about HRT & Breast Cancer that you may find useful:

MHRA HRT & Breast Cancer - https://assets.publishing.service.gov.uk/media/5d68d0e340f0b607c6dcb697/HRT-patient-sheet-3008.pdf

After completing all of the above questionnaire, please click submit below. Your GP practice will then inform you if your HRT repeat prescription is ready for collection or if a further assessment is required.

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HRT Review

Please only complete the following questionnaire if requested by your GP practice as part of your routine review.

Please see the following links for further information on the HRT that you may find useful:

Please see the following links for further information about HRT & Breast Cancer that you may find useful:

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