HRT Review Form

Only complete the following questionnaire if requested by your GP practice as part of your routine HRT review.

Please allow 5 days for the review and prescription of the HRT requested. If you have not had a response from the practice within 7 days, please contact the practice.  Tel: 01727 832125

Last Updated: 16/09/2024

  • Personal Details

    This questionnaire is for a routine review of your HRT. If you are experiencing any of the following ring your GP immediately:

    • Painful swelling of your leg
    • Weakness or numbness of an arm or leg
    • Sudden problems with your speech or sight
    • Difficulty breathing
    • Coughing up blood
    • Pains in your chest, especially if it hurts to breathe in
    • Unexpected vaginal bleeding
    • Persistent irregular vaginal bleeding
    • Breast lump, persistent breast pain, or nipple changes
    • Abdominal pain, discomfort or bloating
    • Weight loss that is not intended
    Your Date of Birth
    For example, 15 3 1984

  • Your Health Details

    When was your last period
    For example, 15 3 1984
    Have you had a hysterectomy?
    Do you have a current Mirena coil fitted?

  • Your Health Details (Continued)

    Blood Pressure

    How to calculate you Green Score

    A Blood Pressure reading is required before issuing your prescription. 

    A BP machine is available at the surgery reception.

  • Health Checks

    If you answer "Yes" to any of the following questions, do not proceed with the form or submit it. Please call Midway Surgery to book an appointment to discuss your medication further

    Have you been experiencing side effects since you started HRT?
    Have you considered reducing or stopping your HRT?
    Have you experienced any persistent unexpected bleeding, or increased bleeding?
    Have you ever had any blood clots? (eg. deep vein thrombosis or pulmonary embolism)
    Have you ever had a heart attack or stroke?
    Have you ever had breast cancer or endometrial cancer?
    Have you ever had liver or gallbladder disease?
    Do you have any family history of any of the following? (Please select all that apply)

  • IMPORTANT NOTICE

    A reminder that if you answered "Yes" to any of the previous questions, do not proceed with the form or submit it. Please call Midway Surgery to book an appointment to discuss your medication further

  • Health Checks - continued

    Are you currently using contraception?
    Do you regularly self-check your breasts?
    Are you up to date with your mammograms?

  • Lifestyle

    Alcohol Consumption - why not try this online alcohol unit calculator.  Alterantively you can use the list below.

    The following is one unit of alcohol:

    • Half a pint of Beer/Lager or Cider
    • 1 small glass of wine
    • 1 single measure of spirit
    • 1 single measure of aperitif
    • 1 small glass of sherry

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

    • Pint of regular Beer/Lager/Cider - 2 units
    • Pint of Premium Beer/Lager/Cider - 3 units
    • Alcopop or can/bottle of Regular Lager - 1.5 units
    • Can of Premium Lager or Strong Beer - 2 units
    • Can of Super Strength Lager - 4 units
    • Glass of wine (175ml) - 2 units
    • Bottle of wine - 9 units
    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?

  • Lifestyle (Continued)

    Smoking

    What is your smoking status?
    Do you use an e-cigarette?

  • Disclaimer

    If you are unable to answer yes to the below statements you will not be able to submit this review form.

    Please book a telephone consultation to discuss this before the next repeat prescription is dispensed.

    wellspring+ | RISKS website

    I confirm that this is a repeat prescription request
    I confirm that I am aware of how to take my HRT
    I confirm that I am aware of the potential risks associated with HRT use and have read this website wellspring+ | RISKS (link in the header of the disclaimer)
    I confirm that any medication prescribed for me is for my personal use only and that I have responded honestly and provided complete and accurate information
    I am aware that I can book an appointment to discuss any further concerns I have with my HRT treatment
    I confirm that any medication prescribed for me is for my personal use only and that I have responded honestly and provided complete and accurate information

  • Wrap-up

    Should you have any requests about your HRT, please call the surgery and book a telephone call with a clinician

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.