Keith Health Centre

Turner Street, Keith, AB55 5DJ

Telephone: 0345 337 9944 | Prescriptions: 01542 881001

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Opening Times

Monday
08:00am to 06:00pm
Tuesday
08:00am to 06:00pm
Wednesday
08:00am to 06:00pm
Thursday
08:00am to 06:00pm
Friday
08:00am to 06:00pm
Saturday
CLOSED
Sunday
CLOSED

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Hormone Replacement Therapy (HRT) Review Form

I confirm that I am a registered patient at Keith Health Centre.(Required)
Yes
Name(Required)
First Last
Date of Birth(Required)
DD slash MM slash YYYY

Email(Required)

Contact telephone number(Required)
Address(Required)
Street Address City County / State / Region Postcode Country

What type of HRT do you use? Please include the name and dose, if known(Required)
Do you have a hormonal coil in place? eg Mirena, Jaydess or Kyleena coil(Required)

Yes

No

Not sure
If you answered YES to the previous question, please tell us the type of coil and when you had it fitted
Do you need contraception?*(Required)

Yes

No
*HRT is not a contraceptive. You will require contraception in addition to your HRT unless you have a Mirena coil as part of your HRT or if you are over 55 years of age.
How long have you been taking HRT?(Required)
Do you still have periods?(Required)

Yes

No
Have you noticed any recent change in your bleeding pattern?

Yes

No
Do you have any problems or side-effects with your HRT that you would like to discuss further?

Yes

No
Do you have any symptoms that are not well controlled on HRT?

Yes

No
If you find that HRT is not controlling your menopausal symptoms , eg hot flushes, mood problems, vaginal dryness, pain/discomfort during sex, please make a GP appointment to discuss.
Do you ever miss or forget to take your HRT?(Required)

Yes

No
If you are taking HRT in separate preparations, it is important, for safety reasons, to take both as prescribed.
Have you had surgery to remove your womb (hysterectomy)?(Required)

Yes

No
If you answered YES to the previous question, when did you have a hysterectomy?
Do you have any new breast symptoms?(Required)

Yes

No
We recommend accepting invitations to attend National Breast Screening (mammography) from the age of 50yrs, as well as examining your breasts regularly for any changes.
Have you or any of your parent(s) sibling(s) been diagnosed with breast or ovarian cancer?(Required)

Yes

No
If you answered YES to the previous question, please tell us which family member(s) have been affected by breast cancer.
Have you or any of your parent(s) or sibling(s) been diagnosed with a blood clot (deep vein thrombosis (DVT) in the leg or pulmonary embolus in the lung)?(Required)

Yes

No

Don't know
Do you suffer with migraines associated with a visual aura, weakness or numbness?(Required)

Yes

No
If you answered YES to the previous question, how often do you get your headaches or migraines?
Are you currently or have your recently used any weight loss medications or injections? eg Mounjaro

Yes

No
Please tell us your weight? (optional)
Please tell us your height? (optional)
Have you taken a blood pressure reading within the last month?(Required)

Yes

No

No, but I had my blood pressure measured at the surgery
If yes, please provide your blood pressure reading with your systolic (upper) and diastolic (lower) values (for example: 120/80
Are you a smoker?

Yes

No
If you answered YES to the previous question, please tell us how many cigarettes you smoke daily?
Do you have any allergies?

Yes

No
If you answered YES to the previous question, please tell us what allergies you have:
Are you up to date with cervical screening?

Yes

No

Not sure
Are you interested in gradually reducing or stopping your HRT?

Yes

No
Is there anything else you would like to tell us that we have not asked? (Please answer below)
What is the best way for us to respond to this request for HRT? Please be aware that you may be called in for an HRT review from time to time, based on the answers to these questions.

Text - (supply up to date number below)

Email (supply email address)

Phone (supply phone number if different from above)
Contact Details (as requested above)
PLEASE READ THE FOLLOWING INFORMATION AND TICK THE BOX BELOW TO ACKNOWLEDGE YOUR UNDERSTANDING:

Most women benefit from HRT in terms of health and quality of life. There are, however, some risks to HRT which should be considered.

HRT can carry a small increased risk of breast cancer. It is important to take your HRT correctly, as prescribed, to protect the womb lining from thickening, which can increase the risk of cancer of the womb. There is also an increased risk of blood clots depending on the type of HRT prescribed and individual risk factors. Health benefits and reduced risks can be gained by eating a healthy diet, regular exercise, not smoking, restricting alcohol consumption to recommended limits and maintaining a healthy weight where possible. It is also important to attend regularly for cervical smears and breast screening as indicated and to be breast aware and examine your breasts regularly and report any changes to your doctor.

If you would like to read more about the benefits and small risks of HRT, there are many websites offering advice:

Understanding the risks of breast cancer

HRT: Benefits and risks

Menopause Factsheets

Rockmy: Get Informed

Menopause Matters

Disclaimer(Required)

I have read and understood the risks described above.

Privacy Policy and Terms - 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 team to contact you and also to update your medical records. Please read our Privacy Policy to discover how we protect and manage your submitted data. I CONSENT TO THE PRACTICE COLLECTING AND STORING MY DATA FROM THIS FORM.(Required)

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