HRT (Hormone Replacement Therapy) Review

Only complete this form on request from the Practice.

HRT (Hormone Replacement Therapy) Review

HRT (Hormone Replacement Therapy) Review

Section

BMI

e.g. 1.75
e.g. 60.6
Please note: BMI calculator is only for patients aged 18 and over.

Blood Pressure

Please note if you are unable to provide a blood pressure reading, Reception will reply to arrange a HCA appointment.

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Review

Do you smoke? *
Do you find HRT effective? *
Are you experiencing any side effects? (e.g. Migraines) *
Has there been any changes to your health since your last HRT check? *
Has there been any changes to your medications since your last HRT check? *
Do you have any vaginal dryness or discomfort? *
Are you attending the following recommended screening programmes?
Cytology: *
Mammography: *
Breast awareness: *
Do you have any concerns about vaginal bleeding? *
Do you need contraception? *
*