HRT Review form

If you have been requested to submit an HRT review, please complete this form.

Please complete your details below

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Telephone Number

Email address (optional)

Which clinician asked you to submit this form?

Dr Jaffrey

Dr Simpson

Dr Barr

Dr Crawley

Dr Dallman

Dr Khanam

Dr Patterson

Nurse Susie Simpson

Pharmacist Fiona Burt

Other (Please Specify)

Please enter details here
Your Health

As part of the review of your HRT we need some up to date details about your health. A blood pressure reading can be done at home, by attending your local pharmacy or alternatively an appointment can be made with our practice Healthcare Assistant

Alcohol unit calculator:

https://alcoholchange.org.uk/alcohol-facts/interactive-tools/unit-calculator

blood pressure

height

weight

Do you smoke?

Yes

No

Ex-Smoker

(If yes, how many per day?)

Please enter details here

When was your last period, and how have your periods been over the last 12 months?

How many units of alcohol do you typically drink in a week? (link to calculator above)

Have you ever had any of the following conditions? (optional)

Blood clots or a clotting disorder

Stroke

Heart Disease

Liver Disease

Migraine

Breast or Ovarian conditions

(Please Specify)

Please enter details here

Have you had a hysterectomy (an operation to remove your womb)?

Yes

No

If so, was this a full or partial hysterectomy, and do you have smear tests? (optional)

Do you have a history of endometriosis?

Yes

No

Do you have a mirena coil in place?

Yes

No

If yes, when was this fitted?

Please enter details here

Do you have any unexpected spotting or bleeding, e.g. after sex or between periods?

Do you take any over the counter or non prescribed medication?

Are you up to date with your breast screening (Mammogram)?

Yes

No

Are you up to date with your cervical screening?

Yes

No

Do you have a family history of breast cancer?

Yes

No

Are you currently using contraception? (please note hrt does not act as contraception)

Yes

No

Do you have any vaginal dryness or discomfort?

Yes

No
Menopause Symptom Score

Please answer the following questionnaire and input your total score below

Psychological and Emotional symptoms - Over the past 3 months have you noticed any changes in your mood, being more irritable or anxious, changes to your confidence or memory?

5 - Always

4 - More than half the time

3 - About half the time

2 - Less than half the time

1 - Rarely

0 - Never

Vulva/vaginal symptoms: over the last 6 months, have you experienced any irritation, dryness or soreness or discharge in the vulva (outside part of female genitals) or vagina?

5 - Always

4 - More than half the time

3 - About half the time

2 - Less than half the time

1 - Rarely

0 - Never

Urinary symptoms: Has there been a change in the way you urinate (pass water) to more frequent or more urgently?

5 - Always

4 - More than half the time

3 - About half the time

2 - Less than half the time

1 - Rarely

0 - Never

Physiological Symptoms: Have you experienced any of the following symptoms in the last 3 months: Palpitations- or your heart racing fast, sweats, flushing, night sweats, unable to sleep, headaches joint pains, tiredness or stomach bloating

5 - Always

4 - More than half the time

3 - About half the time

2 - Less than half the time

1 - Rarely

0 - Never

Bleeding or Period symptoms: Have you experienced changes to your bleeding pattern with spotting, irregular, heavy or missed periods

5 - Always

4 - More than half the time

3 - About half the time

2 - Less than half the time

1 - Rarely

0 - Never

Total Score (0-25)
For those already prescribed HRT

Please only complete the below if you are currently taking HRT

Is your HRT helping your symptoms? (optional)

Yes

No

How long have you been taking HRT? (optional)

Are you having any side effects or problems with your HRT? (optional)

Do you want to continue HRT? (optional)

Yes

No

Is there anything else regarding your HRT you wish to change or discuss? (optional)
Consent

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.

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HRT Review form

HRT Review form

Please complete your details below

Your Health

Menopause Symptom Score

For those already prescribed HRT

Consent