HRT Review

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 *

I consent to the practice collecting and storing my data from this form

Are you happy with your current HRT regime? *

Yes No

Do you experience any unwanted side effects? *

Yes No

Since your last HRT review have you experienced any new or irregular vaginal bleeding? *

Yes No

Please confirm that you take your HRT in the dose(s) instructed on your prescription: *

Yes No

If you use a Mirena Coil as part of your HRT regime, please enter the date it was last changed: *

Please confirm that you self examine your breasts on a regular basis and are up to date with breast screening: *

Yes No

Please provide a recent blood pressure reading: *

Please confirm that you have read the information below on the benefits and risks of HRT and have made an informed decision to continue: *

Yes No

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HRT Review

Further Information