Hormone Replacement Therapy Review

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

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
Hormone Replacement Therapy Review
Please enter Date of Birth as DD/MM/YYYY
Your Lifestyle- Alcohol
Your Lifestyle- Smoking
Further Questions

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

Menopause Matters - https://www.menopausematters.co.uk/

NHS - https://www.nhs.uk/conditions/menopause/

Patient.info Menopause - https://patient.info/womens-health/menopause

Patient.info HRT - https://patient.info/womens-health/menopause/hormone-replacement-therapy-hrt

Patient.info Alternatives to HRT - https://patient.info/womens-health/menopause/alternatives-to-hrt

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

MHRA HRT & Breast Cancer - https://assets.publishing.service.gov.uk/media/5d68d0e340f0b607c6dcb697/HRT-patient-sheet-3008.pdf

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This information is not shared with any third party organisations.

This information is retained for up to 28 days.

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