HRT Questionnaire

Thank you for completing this form. We are aiming to avoid the need for you to see a clinician in order to re-issue your HRT. WE ARE UNABLE TO ISSUE A PRESCRIPTION WITHOUT UP TO DATE BLOOD PRESSURE AND WEIGHT MEASUREMENTS. Blood Pressure machines available at reception if you don’t have one at home.

For information on HRT Myths click here

For information on HRT medication types & doses click here

You might want to monitor your symptoms and is worth doing regularly to assess how symptoms change with time or with treatment. Download the Menopause Symptoms Questionnaire here or download the balance app to take the balance Menopause Symptom Questionnaire

Please note it will take 4 working days to generate your prescription.

HRT Questionnaire
Have you had any problems or concerns with your HRT? *
Do you have breast tenderness or changes? *
Do you examine your breasts regularly? *
Are you up to date with the recommended screening programs, e.g. smears, breast screening over 50? *
Do you feel nauseous (sick)? *
Do you have headaches? *
Do you have any bleeding which is abnormal? *
Do you smoke? *
How often do you have an alcoholic drink? *
How many standard* alcoholic drinks do you have on a typical day when you are drinking (*A standard alcoholic drink is 1 unit of alcohol = a small glass of wine, a pub measure of spirits or half pint of lager/beer) *
How often do you have 6+ standard alcoholic drinks on one occasion? *
Do you want to speak to your GP or Pharmacist about your HRT medication?
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