HRT Review Form

Thank you for completing this form. We are aiming to avoid the need for you to see a clinician in order to re-issue your HRT prescription. Once completed, please hand the form to reception and we will generate your next 12-month supply of HRT. Scales and a blood pressure machine can be found in the waiting area – we are unable to issue a repeat prescription without up-to-date blood pressure and weight measurements.  Please note, it will take a week to generate your prescription.

HRT Review
Please use format day/month/year e.g. 12/05/1979

Height and weight

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Blood pressure

Your blood pressure reading is made up of 2 numbers. Enter the highest number first. This is the highest level your blood pressure reaches when your heart beats (systolic). Then enter the lower number. This is the lowest level your blood pressure reaches when your heart relaxes between beats (diastolic).

Your health

Have you had any problems or concerns with your HRT?
Are you up to date with breast screening?
Do you examine your breasts regularly?
Do you have any new breast lumps or changes?
Have you had a hysterectomy? (Surgery to remove your womb)
Do you have a hormonal coil ? (Mirena)
Do you have any bleeding which is abnormal?
Do you have any bleeding after sex?
Do you feel at risk from abuse or violence?
Smoking status
How many cigarettes do you smoke each day?
How often do you drink alcohol?
How many standard alcoholic drinks do you have on a typical day when your drinking?
* A standard alcoholic drink is 1 unit of alcohol – a small glass of wine, a pub measure of spirits or half a pint of lager/beer.
How often do you have 6 standard alcoholic drinks on one occasion?
* A standard alcoholic drink is 1 unit of alcohol – a small glass of wine, a pub measure of spirits or half a pint of lager/beer.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.