HRT Review Questionnaire

In order to provide HRT safely we need to ask you some questions. We would be grateful if you could complete this form when you submit your repeat prescription request. If you are having any problems with your HRT medication or would like to consider alternative options, please speak to one of our trained clinicians.

This questionnaire is to support the review of your HRT. If your menopause symptoms are well managed you may not need an appointment and an HRT review could be documented virtually, please ensure you include your blood pressure reading.

If you still have symptoms and are on less than a 100mcg patch or less than 4 pumps of oestrogel or less than 2mg sandrena then we may look to gradually increase your prescription, stopping at the lowest dose that settles your symptoms, and review you in 8 weeks

HRT Review Questionnaire

HRT Review Questionnaire


What would you like to happen following completion of this questionnaire (please select all that apply)?

Please note it is best practice to ensure you are on a good dose of oestrogen first, we would look to ensure this is the case and check blood tests prior to testosterone prescribing. An appointment will be made as per your preference above with a GP to discuss testosterone. Please confirm you have read the following leaflet and wish to proceed: Testosterone replacement in menopause - British Menopause Society:


Blood Pressure

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


What dose of HRT are you currently taking?

Oestrogen (if applicable)

Progesterone (if applicable)

Please select one of the following:
Please use date format: DD/MM/YYYY

Do you have a history of endometriosis? *
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? *
Are you known to have the BRCA gene?
Have you had a hysterectomy? *
Have you had any unexpected bleeding since starting HRT including after sex? *
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 bleeding is common in the first 3-6 months on HRT but if I have any irregular bleeding that starts after that or persists, I will arrange a review appointment: *

Smear Tests

For information regarding smear tests, please visit

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 Cancer

There may be an increased risk of breast cancer, depending on the type of HRT that you are taking. Please read the following infographic to give more details about how the risk of breast cancer compares to other lifestyle risk factors: Understanding the risks of breast cancer

Breast Screening

For information on breast screening, please visit

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.

Menopause Information

For more information about the menopause, please vist


Menopause Symptom Scale (Greene Climacteric)

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: *
Please send us a copy of any relevant paperwork for our records.
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