HRT Questionnaire

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Personal Details

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In order to provide HRT safely we need to ask you some questions. We would be grateful if you could complete this form when you submit your repeat prescription request. If we are having any problems with your HRT medication or would llike to consider alternative options. Please speak to one of our trained clincians.

How do you take your HRT?: *

What is the reason for you taking HRT?: *

What is your smoking status?: *

If you answered yes to smoking - and would like support in quitting. Please ask at reception about quitting or visit Live Life better Derbyshire website

https://www.livelifebetterderbyshire.org.uk/services/stopping-smoking/stopping-smoking.aspx

Do you have parents, brothers, sisters or children who have had heart disease or a stroke under the age of 45?: *

Do you have parents, siblings or children who have had a blood clot?: *

Have you had a Deep Vein Thrombosis or a Pulmonary Embolous?: *

Do you have any blood clotting abnormalities: *

Do you have diabetes?: *

Do you have any family history of breast cancer under the age of 50: *

Have you had a hysterectomy?: *

Do you know how your HRT works?: *

Do you understand that menopausal symptoms can be reduced by being the right weight for your height?: *

Do you understand that rarely HRT can cause a clot and the symptoms/signs of a blood clott are calf pain and swelling, sharp chest pains, shortness of breath and coughing up blood: *

Do you understand that HRT increases your risk of breast cancer and you agree to examine your breasts every month and to attend breast cancer screening when offered. The risk increases the longer you are on HRT and persists after the HRT has been stopped.: *

Do you understand that you should tell a healthcare professional that you are on HRT if you need to have an operation or have a period of prolonged immobilisation eg leg in plaster: *

Do you understand that irregular vaginal bleeding on HRT should be reported to a clinician: *

Are you up to date with your cervical smear and breast screening?: *

Have you been on HRT for longer than 5 years? : *

If you answered No to the above question please contact reception to arrange your overdue cervical smear and to ask regarding your breast screening review.

Thank you for completing our HRT questionnaire.

If there are any problems with re-issuing your prescription we will contact you.

If not your prescription will be ready for you to collect from your nominated pharamcy within 2 working days.

If you do not have a nominated pharmacy please contact reception and we can set this up on your medical records.

Privacy Consent

This form collects personal and medical informanot tion about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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HRT Questionnaire

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