Hormone Replacement Therapy (HRT) Review

This form should only be used for people currently prescribed HRT.

Hormone Replacement Therapy (HRT) Review

Smoking Status:
Would you like help to quit smoking?
Do you drink any alcohol?

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Blood Pressure

Review

Are you currently using any contraception?
Have you had a hysterectomy?
Do you have a Mirena coil fitted?
Do you have any vaginal bleeding?
Do you bleed after having sex?
Are you currently experiencing any of the following symptoms?
Do you experience any of the following side effects?
Do you have a history of blood clots, breast cancer or endometrial cancer?
Do any of you close relatives (I.e. parent, sibling or offspring) have a history of blood clots, breast cancer or endometrial cancer?
When was the last time you experienced menopausal symptoms?
Would you like to consider reducing your HRT?

Cervical Screening

Please visit www.nhs.uk/conditions/cervical-screening for further information on cervical screening.

I confirm: *

It is important whilst you take HRT that you regularly check your breasts. Please follow the link to information on how to do this:

*