HRT Review

If you have been advised by the surgery to do so, please complete this form.

There is a slightly increased risk of breast cancer with HRT use which varies with the type of HRT and duration of use.

HRT Review

HRT Review

Section

Duration of use (approximately):

Have you had a hysterectomy? *
Do you have a Mirena Coil? *

Please answer the following questions about your HRT

Is it helping? *
Have you had any new health problems since you last HRT check? *
Have you started any new medications since your last check? *
Have you had any new sexual partners since your last check? *

You may be asked to contact your Doctor to discuss the above.

Are you using contraception? *

Please read the following:

  • If you are under 50 years you will need contraception for two years after the menopause.
  • If you are over 50 years you will need contraception for one year after the menopause.
  • The menopause is defined as no periods for one year. This will not be reliable if you have been taking hormones.
*

Examination

Blood Pressure

BMI

e.g 1.75
e.g 60.6

Health Risks

Do you have a history of VTE (deep vein thrombosis or pulmonary embolism)? *
Do you have a family history of VTE (deep vein thrombosis or pulmonary embolism)? *
Do you have a history of migraines? *
Do you smoke? *
*