HRT Review Form

You will need an up to date blood pressure reading before you complete the online details. This can easily be organised using a home monitoring machine or through local pharmacies. Please record this before you complete this form.

HRT Review Form

Name

First Last

Date of birth

DD slash MM slash YYYY

Preferred contact telephone number

Email Optional

Height and Weight

Height (ft in)

Weight (st lbs)

HRT Review

Are you happy with your current HRT?

Yes

Your blood pressure reading

e.g. 120/70

Do you smoke?

Yes

Have you ever had a blood clot, heart disease, stroke, cancer, migraine or major illness?

Yes

Do you still need contraception?

Yes

Are you suffering any menopausal symptoms?

Yes

If yes please give details below Optional

Have you had a hysterectomy?

Yes

Do you have a coil in?

Yes

Do you understand and have you read about all the risks and benefits of taking HRT?

Yes

Any comments you would like to add? Optional

Privacy Notice

I consent to the practice collecting and storing my data on this form

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice. Please read our Privacy Notice for details of how we protect and manage submitted data.

Staff Training

Please note the Practice will be closed every Thursday between 1pm-2pm for staff training.

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