HRT Repeat Prescription 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.

HRT Repeat Prescription Questionnaire

HRT Repeat Prescription Questionnaire


Blood Pressure

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

What is the reason for you taking HRT? *
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? *
Have you had a hysterectomy? *
Do you have a mirena coil in place, that was inserted in the last 5 years? *
Please use date format: DD/MM/YYYY
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 vaginal bleeding on HRT should be reported to a clinician: *

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 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

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:


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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