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Hormone Replacement Therapy
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HRT
Complete the eReview below for a repeat of your HRT. You will not need to attend the surgery. Record a blood pressure using a home blood pressure machine. (maybe insert how to take reading)
It is important that you research alternatives and understand the benefits and risks linked to HRT.
First Name
*
Last Name
*
Email
*
Enter Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Your Height and Weight
Weight
Unit of measurement
*
Metric
Imperial
Height
cm
Weight
kg
Height
ft
Inches
in
Weight
lbs
BMI
BMI
Underweight
Healthy
Overweight
Obese
HRT Review
Are you happy with your current HRT?
*
Yes
No
Your blood pressure reading
*
Do you smoke?
*
Yes
No
Have you ever had a blood clot, heart disease, stroke, cancer, migraine or major illness?
*
Yes
No
Are you still in need of contraception?
*
Yes
No
Are you suffering any menopausal symptoms?
*
Yes
No
Have you had a hysterectomy?
*
Yes
No
Do you have a coil in?
*
Yes
No
Do you understand and have you read about all the risk and benefits of taking HRT?
*
Yes
No
Best number to call you on
*
One of our clinicians will contact you on this number in the next couple of weeks.
Please add a comment about your experience with your HRT prescription. The Practice will be in contact soon.
*
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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