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HRT prescription start questionnaire

HRT Prescription Start Questionnaire
Required fields are labelled
You must be aged 13 or over to complete this form yourself
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

Assessment questions

Have you noticed any bleeding between periods or after sex? Required
Have you had a hysterectomy? Required
Do you have a mirena coil in place? Required

For information about the coil, please visit www.sexwise.org.uk/contraception/ius-intrauterine-system

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) Required
Smoking status: Required
Do you have parents or brothers or sisters or children who have had heart disease or stroke under the age of 45? Required
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)? Required
Have you had a blood clot? Required
Do you have any blood clotting abnormalities? Required
Do you have any family history of breast cancer under the age of 50? Required
Do you experience migraines? Required
Do you have a history of heart disease? Required

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.

Please read the following NHS Information: www.nhs.uk/hormone-replacement-therapy-hrt/risks

Please read more information about HRT and 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:

www.menopausedoctor.co.uk/menopause

Confirmation Required

Alcohol and measurements

In Units

Blood Pressure

What is your most recent blood pressure reading? (This can be checked at reception, home or work)

Further information

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? Required

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 with HRT despite these risks.

You understand that rarely oral oestrogen as part of HRT can cause a clot and the symptoms/signs of a blood clot are calf pain and swelling, sharp chest pains, shortness of breath and coughing up blood and will seek urgent medical attention if these symptoms occur: Required
You understand that you should tell a healthcare professional that you are on HRT (if you take oral oestrogen) if you need to have an operation or have a period of prolonged immobilisation e.g. leg in plaster: Required
You understand that irregular vaginal bleeding on HRT should be reported to a clinician: Required

Smear Tests

For information regarding smear tests, please visit www.nhs.uk/conditions/cervical-screening.

Please note 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? Required

Breast Screening

For information on breast screening, please visit www.nhs.uk/conditions/breast-screening-mammogram.

Do you consent to being contacted by text message about your HRT and other clinical matters? Required
Do you consent to being contacted by email about your HRT and other clinical matters? Required
You will always receive an automatic submission confirmation email upon submitting this form.

Symptoms

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

Heart beating quickly or strongly: Required
Feeling tense or nervous: Required
Difficulty in sleeping: Required
Excitable: Required
Attacks of anxiety, panic: Required
Difficulty in concentrating: Required
Feeling tired or lacking in energy: Required
Loss of interest in most things: Required
Feeling unhappy or depressed: Required
Crying spells: Required
Irritability: Required
Feeling dizzy or faint: Required
Pressure or tightness in head: Required
Parts of body feeling numb: Required
Headaches: Required
Muscle and joint pains: Required
Loss of feeling in hands or feet: Required
Breathing difficulties: Required
Hot flushes: Required
Sweating at night: Required
Loss of interest in sex: Required
Have you had any incontinence? Required
Have you had vaginal dryness, itching or pain during intercourse? Required
Do you have any other symptoms? Required
Please send us a copy of any relevant paperwork for our records.

Do not upload sensitive photographs of genitalia, bottoms (anus), breasts or minors without asking a healthcare professional first. Your uploads may be stored on your health record.