HRT Review

Please only complete the following questionnaire if requested by your GP practice as part of your routine HRT review.

Your GP practice will then inform you if your HRT repeat prescription is ready for collection or if a further assessment is required.

This questionnaire is for a routine review of your HRT. If you are experiencing any of the following ring your GP immediately:

  • Painful swelling of your leg
  • Weakness or numbness of an arm or leg
  • Sudden problems with your speech or sight
  • Difficulty breathing
  • Coughing up blood
  • Pains in your chest, especially if it hurts to breathe in
  • Unexpected vaginal bleeding
  • Persistent irregular vaginal bleeding
  • Breast lump, persistent breast pain, or nipple changes
  • Abdominal pain, discomfort or bloating
  • Weight loss that is not intended

Please see the following links for further information on the HRT that you may find useful:

Please see the following link for further information about HRT and Breast Cancer that you may find useful:

HRT Review

Section

Do you know the name of the hormone replacement therapy (HRT) that you want?
Have you started taking any new regular medications or health supplements recently?
(Please include any over-the-counter supplements or medications)
Have you been diagnosed with any new health conditions since we last issued your HRT?
(These could be any conditions but in particular: any breast or ovarian conditions, blood clots or a clotting disorder, cancer, heart disease, liver disease, migraines or diabetes)
Is HRT helping your symptoms?
Are you having any side effects or problems from your HRT?
Do you have any vaginal dryness or discomfort?
Are you up to date with your breast screening (mammogram)?
(A mammogram is a type of X-ray that looks for breast cancer. You should be invited to have a mammogram every 3 years between the ages of 50 and 71 unless you have been told otherwise by a healthcare professional)
Are you up to date with your cervical screening (smear test)?
(Unless you have been told otherwise by a healthcare professional, you should be invited to have a smear test every 3 years between the ages of 25 and 49, every 5 years from age 50 to 64 and then over 65 if one of your last 3 smear tests was abnormal)
Do you have a family history of breast cancer?
Have you had any new or unexpected vaginal bleeding/spotting?
(Such as after sex, between periods or after 12 months of not having a period)
Have you had a hysterectomy?
(A hysterectomy is where you’ve had surgery to remove your womb [uterus])
Are you currently using contraception?
(Please note, HRT does not act as contraception)
Do you require advice about contraception?
What is your smoking status?
How much do/did you smoke?
Are you able to provide a blood pressure reading?
(As part of the review of your HRT we need an up-to-date blood pressure reading)
Are you able to provide a weight and height reading?
(If you only know your weight in stone and pounds, please use the converter: Convert weight from Imperial to Metric)
(If you only know your height in feet and inches, please use the converter: Convert height from Imperial to Metric)
Are you considering stopping your HRT?