HRT Review

If this your first prescription please do not complete the form and contact the practice instead.

Name(Required)
DD slash MM slash YYYY

Your Height & Weight

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Blood Pressure

If you have access to home monitor please complete, if not please contact practice to arrange an appointment for it to be taken. There is a BP machine located in waiting area if required. Please let Reception if urgent script required.
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).

Further Details

Do you smoke?(Required)
Have you ever had a blood clot, stroke, heart disease, cancer or other major illness?(Required)
I understand this is not a contraception(Required)
Since your last HRT review have you experienced any unexpected bleeding?(Required)
Including: bleeding after sex; bleeding in between your periods; or (if your periods have stopped) any bleeding more than 12 months after your last period.
Please confirm you have read about and understand the risks and benefits of taking HRT(Required)
Privacy Policy(Required)