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Clackmannan and Kincardine Medical Practice

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Home
New Patients
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Services
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Health Advice
Opening Hours
News
Staff
Contact Us

HRT Review

This form is used for your HRT review.

Please answer the questions and submit this form to us in order for the Practice to continue prescribing your HRT medication.

This form will be reviewed by the Practice and we will contact you if required.

Last Updated: 19/12/2024

Your Details

Name: *

Date of Birth: *

Mobile Phone Number:

Home phone number:

HRT Review

Are you currently taking HRT? *

Yes No

Which HRT medication(s) are you taking? *

How long have you been taking HRT at the current dose? *

Are you taking HRT regularly? (including progesterone if this applies) *

Yes No

Are you having any side effects from your HRT? *

Yes No

If you are having side effects, please describe them:

Have you had any new or unexpected vaginal bleeding or spotting? *

Yes No

Have you had breast screening (mammogram) in the last 3 years? *

Yes No

Do you have a family history of breast cancer? *

Yes No

Have you ever had a blood clot in your lung or vein? Also known as a PE (lung) or DVT (vein).

Yes No

Have you had a hysterectomy? *

Yes No

If you have not had a hysterectomy, do you need contraception?

Yes No

If you have not had a hysterectomy, do you have a mirena coil in place?

Yes No

If you have a mirena coil in place, when is it due for removal/change?

If you have your own blood pressure monitor, what is your blood pressure reading?

If you do not have a blood pressure monitor, please confirm you will contact the practice to make an appointment for a blood pressure check within a month.

Yes

Weight: *

Are you considering stopping HRT? *

Yes No

Is there anything else regarding HRT you would like to discuss or change? *

Do you smoke? *

Yes No

If you smoke, how many do you smoke per day?

How many units of alcohol do you drink per week? *

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Further Information

Carers Support
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