Hormone Replacement Therapy

 
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This form is to be used for the following reasons:

  • If you want a repeat of your current HRT
  • If you have been advised by a clinician to complete this form
Do you wish to start a new HRT or switch to a different HRT: *

In addition to completing this questionnaire you will also be required to submit an online consultation

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All questions marked with a * are mandatory

Personal Details
Please double check you've entered the correct email address
We need this to send you a text when your prescription is ready
May be used to identify you
We need this to be able to issue your prescription
Is this your usual nominated pharmacy?: *
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HRT Review
Do you need a repeat of your current HRT?: *
Do you feel your current HRT medication is helping?: *
Are you aware of risk and benefits of treatment?: *
Do you have any side effects of current drug treatment?: *

Please check your blood pressure (if you do not have access to a blood pressure monitor or weighing scales, please call reception to book a blood pressure appointment. A recent reading (within the last 6 months) will suffice

Do you have any irregular bleeding down below? (In women with a uterus, unscheduled vaginal bleeding is a common side effect of HRT within the first 3 months of treatment but should be reported at the 3 month review appointment, or promptly if it occurs after the first 3 months): *
Please let us know if you suffer with any of the following?:
Please tick all that apply.
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Personal History
Do you have a history of any of the following types of cancers?: *
Please tick all that apply
Do you have a history of/current blood clots thrombosis (DVT)?: *
Do you have a history of any of the following? : *
Please tick all that apply
Do you have untreated high blood pressure?: *
Do you have any lactose intolerance?: *
Do you have liver disease?: *
History of or concerns of gall stones: *
History of migraines?: *
Is there any family medical problems associated with the following?: *
Please tick all that apply
Are you pregnant? (it's still possible to get pregnant while taking HRT, so you should use contraception until 2 years after your last period if you're under 50, or for 1 year after the age of 50): *
Do you perform regular self-breast examinations on yourself? : *
Smoking status: *

What does 1 unit of alcohol look like?

Each of the examples depicts 1 unit of alcohol based on the Alcohol by Volume (ABV) against the Volume (ml) displayed.

Click here for NHS guidance about calculating alcohol units

  • Cider

    Cider 218ml

    Standard 4.5% ABV

  • Wine

    Wine 76ml

    Standard 13% ABV

  • Whisky

    Whisky 25ml

    Standard 40% ABV

  • Beer

    Beer 250ml

    Standard 4% ABV

  • Alcopop

    Alcopop 250ml

    Standard 4% ABV

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