HRT Prescriptions HRT Prescription Questionnaire If you are interested in discussing and/or starting HRT please complete the following questionnaire to inform a discussion with one of our clinicians. The following websites are great references for information: Menopause Matters Primary Care Women’s Health Forum Women’s Health Concern My Menopause DoctorName First Last As it appears on your passportDate of Birth Day Month Year Your date of birth is required to verify your identity.Address Postcode The one you used to register with your GP.Sex Female Male Indeterminate As on your medical record.Phone NumberThis phone number will be used for all correspondence relating to this request.Email Address This email address will be used for all correspondence relating to this request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.What menopausal symptoms are you experiencing? OptionalWhat, if any changes have you noticed with your menstrual cycle? (Please detail average gaps between periods, changes in heaviness/lightness of periods, last period if there has been a long gap) OptionalHave you noticed any bleeding between periods or after sex? Yes No Have you had a hysterectomy? Yes No Do you have a Mirena coil in place? Yes No When was this fitted? Day Optional Month Optional Year Optional For information about the coil, please visit www.sexwise.org.uk/contraception/ius-intrauterine-systemAre 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) Yes No Smoking status: Smoker Ex Smoker Never Smoked How many do you smoke per day? Optional Do you have parents or brothers or sisters or children who have had heart disease or stroke under the age of 45? Yes No 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)? Yes No Have you had a blood clot? Yes No Do you have any blood clotting abnormalities? Yes No HRT Information and LeafletThere 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/conditions/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/ Please confirm that you have read this leaflet and understand the risks and benefits of HRT.What is your average alcohol consumption in a week? Optional In UnitsHeight (in CM): Optional Weight (in KG): Optional Blood PressureWhat is your most recent blood pressure reading? (This can be checked at reception, home or work)Systolic "Higher" Optional Diastolic "Lower" Optional Heart Rate Optional 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? * Yes No 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: Yes No 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: Yes No You understand that irregular vaginal bleeding on HRT should be reported to a clinician: Yes No Smear TestsFor 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.When was your last smear test: Was this done privately or abroad? Yes No Please detail the results of your smear (i.e was it normal/abnormal): Day Month Year Breast ScreeningFor information on breast screening, please visit www.nhs.uk/conditions/breast-screening-mammogram.If you are over 50, when was the date of your last breast screening? Day Month Year Please indicate any questions or concerns you would like to be addressed by our clinical team:Do you consent to being contacted by text message about your HRT and other clinical matters? Yes No Do you consent to being contacted by email about your HRT and other clinical matters? Yes No SymptomsPlease indicate the extent to which you are bothered at the moment by any of these symptoms:Heart beating quickly or strongly: Not at all A little Quite a bit Extremely Feeling tense or nervous: Not at all A little Quite a bit Extremely Difficulty in sleeping: Not at all A little Quite a bit Extremely Excitable: Not at all A little Quite a bit Extremely Attacks of anxiety, panic: Not at all A little Quite a bit Extremely Difficulty in concentrating: Not at all A little Quite a bit Extremely Feeling tired or lacking in energy: Not at all A little Quite a bit Extremely Loss of interest in most things: Not at all A little Quite a bit Extremely Feeling unhappy or depressed: Not at all A little Quite a bit Extremely Crying spells: Not at all A little Quite a bit Extremely Irritability: Not at all A little Quite a bit Extremely Feeling dizzy or faint: Not at all A little Quite a bit Extremely Pressure or tightness in head: Not at all A little Quite a bit Extremely Parts of body feeling numb: Not at all A little Quite a bit Extremely Headaches: Not at all A little Quite a bit Extremely Muscle and joint pains: Not at all A little Quite a bit Extremely Loss of feeling in hands or feet: Not at all A little Quite a bit Extremely Breathing difficulties: Not at all A little Quite a bit Extremely Hot flushes: Not at all A little Quite a bit Extremely Sweating at night: Not at all A little Quite a bit Extremely Loss of interest in sex: Not at all A little Quite a bit Extremely Have you had any incontinence? Not at all A little Quite a bit Extremely Have you had vaginal dryness, itching or pain during intercourse? Not at all A little Quite a bit Extremely Do you have any other symptoms? Yes No Please indicate/detail any additional symptoms: OptionalPlease send us a copy of any relevant paperwork for our records. Optional Drop files here or Select files Max. file size: 50 MB. Name OptionalThis field is for validation purposes and should be left unchanged.
