HRT Prescription Start 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:

HRT Prescription Start Questionnaire

HRT Prescription Start Questionnaire

Section

Have you noticed any bleeding between periods or after sex? *
Have you had a hysterectomy? *
Do you have a mirena coil in place? *
Would you consider having a mirena coil as part of your HRT?
Please use date format: DD/MM/YYYY

For information about the coil, please visit www.sexwise.org.uk/contraception/ius-intrauterine-system

Are 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) *
Smoking status: *

There are many benefits to going smoke free.

Please visit Healthy Surrey for support in taking the first steps to a smoke free you.

Do you have parents or brothers or sisters or children who have had heart disease or stroke under the age of 45? *
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)? *
Have you had a blood clot? *
Do you have any blood clotting abnormalities? *
Do you have any family history of breast cancer under the age of 50? *
Do you experience migraines? *
Do you have a history of heart disease? *

HRT Information and leaflet

There 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

*

In Units

Blood Pressure

What is your most recent blood pressure reading? (This can be checked at reception, home or work)

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? *

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: *
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: *
You understand that irregular vaginal bleeding on HRT should be reported to a clinician: *

Smear Tests

For 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.

Was this done privately or abroad? *

Breast Screening

For information on breast screening, please visit www.nhs.uk/conditions/breast-screening-mammogram.

Do you consent to being contacted by text message about your HRT and other clinical matters? *
Do you consent to being contacted by email about your HRT and other clinical matters? *
You will always receive an automatic submission confirmation email upon submitting this form.

Symptoms

Please indicate the extent to which you are bothered at the moment by any of these symptoms:

Heart beating quickly or strongly: *
Feeling tense or nervous: *
Difficulty in sleeping: *
Excitable: *
Attacks of anxiety, panic: *
Difficulty in concentrating: *
Feeling tired or lacking in energy: *
Loss of interest in most things: *
Feeling unhappy or depressed: *
Crying spells: *
Irritability: *
Feeling dizzy or faint: *
Pressure or tightness in head: *
Parts of body feeling numb: *
Headaches: *
Muscle and joint pains: *
Loss of feeling in hands or feet: *
Breathing difficulties: *
Hot flushes: *
Sweating at night: *
Loss of interest in sex: *
Have you had any incontinence? *
Have you had vaginal dryness, itching or pain during intercourse? *
Do you have any other symptoms? *
Please send us a copy of any relevant paperwork for our records.
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