HRT repeat request

HRT repeat request
Please complete the questions below. You will need to enter your blood pressure, height and weight. Many people have their own machines to measure blood pressure. If you are unable to measure your blood pressure at home, please ask at reception to borrow our machine to use on the premises.
Name*

First NameLast Name
Date of Birth*
Phone Number*
Email
example@example.com
Weight in kilograms
Height in metres
Systolic blood pressure (higher number)*
Diastolic blood pressure (lower number)*
What is the name of your HRT?
Have you started taking any new regular medications or health supplements recently? If so please give the names.*
Have you been diagnosed with any new health conditions since we last prescribed your HRT? These could be any conditions, but in particular breast or ovarian conditions, blood clots, cancer, heart disease, clotting disorders, liver disease, migraines or diabetes. If so please describe.*
Do you have any new breast lumps?

YesNo
Is HRT helping your symptoms

yesno
Are you having and side effects or problems with your HRT?
Are you up to date with your breast screening mammograms? These are usually every 3 years between the ages of 50 and 70.

yesnodon't know
Are you up to date with your cervical screening (smear test)? These are usually every 3 years age 25-49 and every 5 years age 50-64

yesnodon't know
Do you have a family history of breast cancer? If so please describe.
Have you had any unusual bleeding eg after sex, in between periods or after 12 months of no periods? If so, please describe
Have you had a hysterectomy (operation to remove the womb)?

yesno
Have you ever had a DVT or PE (blood clot in the leg or lungs)?

YesNo
Please describe
Do you have a family history of DVT or PE (blood clot in the leg or lungs)in a first degree relative?

YesNo
Which relative?

MotherFatherSisterBrotherAuntUncleMaternal grandmotherMaternal grandfatherPaternal grandmotherPaternal grandfather
Do you suffer from migraine

YesNo
Please describe
Are you currently using contraception? What method are you using? Please note that other than the Mirena coil, HRT does not act as contraception. Please book an appointment if you require advice about contraception.
Are you considering stopping your HRT

yesno
What is your smoking status?*

Never smoked tobaccoCigarette smokerEx-smokerRoll my own cigarettesVaper / e-cigarette smokerOther
I understand that smoking is damaging to health, and increases the risk of blood clots if I am also taking HRT. I know that if I am a smoker I can contact reception to ask for help to stop smoking

Yes, I understand
Please read the information in these links:

Treatment of menopause symptoms

Menopause information

HRT factsheet
Please tick here to confirm you have read and understood the information in the links above*

Yes, I understand
I confirm all the information I have supplied is correct to the best of my knowledge. Signature:

Clear
Should be Empty: