HRT Review Form Hormone Replacement Therapy Review Form Full Name * Date of Birth * Contact telephone number * Email Height and Weight Height (ft in) * Weight (st lbs) * HRT Review Are you happy with your current HRT? * Yes No Your blood pressure reading (e.g. 120/70) * Do you smoke? * Yes No Have you ever had a blood clot, heart disease, stroke, cancer, migraine or major illness? * Yes No Do you still need contraception? * Yes No Are you suffering from any menopausal symptoms? * Yes No Have you had a hysterectomy? * Yes No Do you have a coil in? * Yes No Do you understand the risks and benefits of taking HRT * Yes No Any comments you would like to add? * I consent to the practice collecting and storing my data from this form Submit If you are human, leave this field blank.
