HRT Review Name First Last Date of Birth Day Month Year Contact NumberEmail Enter Email Confirm Email Sex Male Female Indeterminate Name of HRT in use: Duration of use (approximately):Years: Months: Have you had a hysterectomy? Yes Optional No Optional Do you have a Mirena Coil? Yes No Please answer the following questions about your HRTIs it helping? Yes Optional No Optional Please provide details:Have you had any new health problems since you last HRT check? Yes No Have you started any new medications since your last check? Yes No Have you had any new sexual partners since your last check? Yes No You may be asked to contact your Doctor to discuss the above.Are you using contraception? Yes No – If you are under 50 years you will need contraception for two years after the menopause. – If you are over 50 years you will need contraception for one year after the menopause. – The menopause is defined as no periods for one year. This will not be reliable if you have been taking hormones.Consent I confirm that I have read the information aboveBlood PressureSystolic "Higher" Optional Diastolic "Lower" Optional Heart Rate Optional BMIStanding Height (in Meters/cm): e.g 1.75Weight (in Kilograms): e.g 60.6BMI: Optional Health RisksDo you have a history of VTE (deep vein thrombosis or pulmonary embolism)? Yes No Do you have a family history of VTE (deep vein thrombosis or pulmonary embolism)? Yes No How much alcohol you do you drink in units per week? Do you have a history of migraines? Yes No Do you smoke? Yes No Consent I confirm that the information provided is correct Optional I understand that unless I hear from my doctor, my HRT prescription will be available to collect within 2 working days Optional
