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HRT Prescription Start Questionnaire

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Personal Details

Sex: *

Please double check you've entered the correct email address

May be used to identify you

Do you consent to being contacted by text message about your HRT and other clinical matters?: *

Do you consent to being contacted by email about your HRT and other clinical matters?: *

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Initial Question

Have you noticed any bleeding between periods or after sex?: *

Have you had a hysterectomy?: *

Do you have a mirena coil in place?: *

More information about the coil

Are you currently using contraception or do you require ongoing contraception: *

Contraception is recommended for all sexually active women under the age of 55 years unless your periods have stopped for over a year off hormones

Smoking status: *

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

Do you have parents or brothers or sisters or children who have had a blood clot: *

sometimes called a deep vein thrombosis or pulmonary embolus

Have you had a blood clot: *

Do you have any blood clotting abnormalities?: *

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

Do you experience migraines?: *

Do you have a history of heart disease?: *

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HRT Information and leaflet

There is little or no increase in breast cancer risk if you take oestrogen only HRT, combined HRT can be associated with a small increased risk. Using vaginal oestrogen for vaginal symptoms is very safe.

Read about the benefits and risks

Please read about HRT & Menopause symptoms so that you can make the most of your 10 minute consultation with the GP in answering any questions you might have about your preferred type of HRT

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About you

In Units

What is your most recent blood pressure reading?

This can be checked with our new machine in our foyer if you do not have access to a blood pressure machine at home.

HRT is not always necessary, and many women find that they can reduce menopausal symptoms through regular exercise; by keeping their weight in a healthy range for their height and reducing alcohol and caffeine. Do you wish to proceed with HRT despite this?: *

To safely prescribe HRT, we need to ensure that you are aware of the risks that may be present with HRT.

Please indicate that you are happy to proceed by answering the following questions.

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Smear Tests

Learn more about Smear Tests

If you find smears uncomfortable you may benefit from some additional vaginal oestrogen pessaries/cream and we would be happy to prescribe these to support you.

Was this done privately or abroad?: *

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Breast Screening

Learn more about breast screenings

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Symptoms

Please indicate the extent to which you are bothered at the moment by any of these symptoms.

Heart beating quickly or strongly: *

Feeling tense or nervous: *

Difficulty in sleeping: *

Excitable: *

Attacks of anxiety, panic: *

Difficulty in concentrating: *

Feeling tired or lacking in energy: *

Loss of interest in most things: *

Feeling unhappy or depressed: *

Crying spells: *

Irritability: *

Feeling dizzy or faint: *

Pressure or tightness in head: *

Parts of body feeling numb: *

Headaches: *

Muscle and joint pains: *

Loss of feeling in hands or feet: *

Breathing difficulties: *

Hot flushes: *

Sweating at night: *

Loss of interest in sex: *

Have you had any incontinence?: *

Have you had vaginal dryness, itching or pain during intercourse?: *

Do you have any other symptoms?: *

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Privacy Consent

This form collects personal and medical information about you and 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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