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HRT repeat prescription questionnaire

HRT repeat prescription questionnaire

Section

Preferred contact method:

Your current HRT

Please copy from your prescription labels
Select the HRT you use:

Systemic oestrogen (patch/gel/spray/tablet)

Route:

Progestogen (if you have a womb/uterus)

Select the type:
Pattern:
Use date format DD/MM/YYYY or state “Unknown”

Local vaginal oestrogen (for dryness/urinary symptoms)

Testosterone (if prescribed)

Use date format DD/MM/YYYY
Use date format DD/MM/YYYY

Adherence / practicalities

In the last 4 weeks, have you missed doses or applied it incorrectly?
Any problems obtaining HRT from pharmacies?
Do you want to continue the same HRT regimen?

Symptom control

Tick any symptoms that are present:
Score based on 0 being “none” and 10 being “worst imaginable” (current symptoms)
Score based on 0 being “none” and 10 being “worst imaginable” (current symptoms)
Score based on 0 being “none” and 10 being “worst imaginable” (current symptoms)
Score based on 0 being “none” and 10 being “worst imaginable” (current symptoms)
Score based on 0 being “none” and 10 being “worst imaginable” (current symptoms)
Score based on 0 being “none” and 10 being “worst imaginable” (current symptoms)
Score based on 0 being “none” and 10 being “worst imaginable” (current symptoms)
Score based on 0 being “none” and 10 being “worst imaginable” (current symptoms)
Overall, how satisfied are you with symptom control?

Vaginal bleeding (important)

Do you currently have a womb/uterus?
Have you had any vaginal bleeding or spotting since your last review?
Use date format DD/MM/YYYY
Pattern:
Timing:
Any clots or flooding?
Any pelvic pain?

Call the surgery or get help from NHS 111 if you have:

  • New bleeding after being period-free on continuous combined HRT
  • Bleeding that is heavy/prolonged or getting worse
  • Bleeding after sex (postcoital bleeding)
  • Bleeding starting more than 6 months after beginning HRT, or more than 3 months after a change in HRT

Side effects / concerns since last review

Have you had any of the following (new or worsening)?

New medical problems / risk changes since last review

Have you been diagnosed with, or treated for, any of the following since your last HRT review?

Call the surgery or get help from NHS 111 if you have:

  • New one-sided leg swelling/pain/redness (possible deep vein thrombosis)
  • New breast lump, nipple discharge, skin dimpling, or persistent focal breast pain

Call 999 or go to A&E if you have:

  • New chest pain, coughing blood, or unexplained shortness of breath (possible pulmonary embolism)
  • Sudden severe headache, weakness/numbness, speech/vision problems (possible stroke)

Breast and cervical screening

Are you up to date with breast screening if eligible (or have you attended when invited)?
Are you up to date with cervical screening if eligible?
Any new family history of breast/ovarian cancer in a close relative?

Contraception / pregnancy (HRT is not contraception)

Could you be pregnant?
Are you currently using contraception?
Use date format DD/MM/YYYY
Are you sexually active with a partner who could get you pregnant?

Current measurements and lifestyle (if known in last 12 months)

mmHg
Measurement:
Measurement:
Smoking status:

Medication changes (interactions)

Since last review have you started any new regular medicines/supplements?
Including over the counter, herbal (St John’s wort)

Further questions

What are you requesting today?

Patient declaration

I confirm the information above is accurate to the best of my knowledge.

Terms and conditions *