Hormone Replacement Therapy Review Form

Email *

Confirm Email *

Date of Birth *

Please use format day/month/year e.g. 12/05/1979

HRT Review

Are you happy with your current HRT? *YesNo

Your blood pressure *

Do you smoke? *YesNo

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

Are you still in need of contraception? *YesNo

Are you suffering any menopausal symptoms? *YesNo

Have you had a hysterectomy? *YesNo

Do you have a coil in? *YesNo

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

Best number to call you on *

One of our clinicians will contact you in the next couple of weeks.

Any comments you would like to add?

Privacy Policy

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 and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *I consent to the practice collecting and storing my data from this form.