Keith Health Centre

Turner Street, Keith, AB55 5DJ

Telephone: 0345 337 9944 | Prescriptions: 01542 881001

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Vacancy for Salaried GP Hayfever and other Allergies Letter to patients about the pressures facing general practice and how we are responding

Friends and Family Test

Near Me Appointments

Order your Prescriptions

Online Appointment Booking

Update your Details

Request for Medical Certificates

Request Medication "not on repeat"

Download Practice Leaflet (readable)

Patient Participation Group

Send your Photos to your GP

Contraception and Sexual Health Guidance

Contraceptive Pill Check Questionnaire

Asthma Control Test (ACT)

Physiotherapy Services

Manual BP Home Monitoring Record Form

Hormone Replacement Therapy (HRT) Review Form

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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Name*
First Last
Date of Birth*
DD dash MM dash YYYY
Address
Street Address Address Line 2 City County / State / Region Postcode Country
Email*
Enter Email Confirm Email
Telephone Number (including mobile number if available*
Name of medication required*
Please copy the name from the original packaging
Dosage*
How much of the medication do you take at a time?
Regularity*
How often do you take the medication?
Prescriber*
Who prescribed the medication, and when?
Reason*
Reason for taking this medication
Date on which medication was last prescribed*
DD slash MM slash YYYY
Date on which your medication runs out*
Additional Information*
Please provide any additional information which will help the Pharmacist, GP or Prescribing Nurse with your request.
Consent*
I agree to the privacy policy.
Signature*
Phone
This field is for validation purposes and should be left unchanged.

30809

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)
MM slash DD slash YYYY

Email(Required)

Contact telephone number(Required)
Address(Required)
Street Address Address Line 2 City County / State / Region Postcode Country

Please tell us the type of hormone replacement therapy (HRT) you are using, including the name and dose, if know(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, if known, please tell us the type of coil and when you had it fitted

How long have you been taking hormone replacement therapy (HRT)?(Required)

Do you have any problems with your HRT?(Required)

Yes

No
If you answered YES to the previous question, please tell us more about the problems you have with your HRT?
Do you ever miss or forget to take your HRT?(Required)

Yes

No
Does your HRT control your hot flushes?(Required)

Yes

No

Somewhat

I don't have hot flushes
Does your HRT control your mood problems?(Required)

Yes

No

Somewhat

I don't have mood problems
Does your HRT control our vaginal dryness?(Required)

Yes

No

Somewhat

I don't have vaginal dryness
Are you sexually active?(Required)

Yes

No
Do you have any pain or discomfort during sex?(Required)

Yes

No
Do you have any bleeding after sex?(Required)

Yes

No
Do you need contraception?(Required)

Yes

No
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 periods or bleeding on your HRT?(Required)

Yes

No
Do you have any unexplained vaginal bleeding?(Required)

Yes

No
Have you also had your ovaries removed?(Required)

Yes

No

Don't know
Do you have any new breast symptoms?(Required)

Yes

No

Not applicable
Have you or any of your parent(s) sibling(s) been diagnosed with breast 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?(Required)

Yes

No

Don't know
Do you get headaches or migraines?(Required)

Yes

No
If you anwered YES to the previous question, have you recently had headaches or migraines?

Yes

No
If you answered YES to the previous question, how often do you get your headaches or migraines?

When you have a headache, do you have to take medication to make it better?

Yes

No
Do you get any visual symptoms, weakness or numbness associated with your headaches/migraines when they occur?

Yes

No
Over the last 2 weeks, how often have you had little interest or pleasure in doing things?(Required)

Not at all

Several days

More than half the days

Nearly every day
Over the last 2 weeks, how often have you felt down, depressed or hopeless?(Required)

Not at all

Several days

More than half the days

Nearly every day
Over the last 2 weeks, how often have you felt nervous, anxious or on edge?(Required)

Not at all

Several days

More than half the days

Nearly every day
Over the last 2 weeks, how often have your not been able to stop or control your worrying?(Required)

Not at all

Several days

More than half the days

Nearly every day
Please tell us your weight? (optional)

Please tell us your height? (optional)

Do you know your blood pressure reading from 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

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 breast screening?(Required)

Yes

No

Not sure
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?

Text

Email

Phone
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)

Yes

15000

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Advertising: Tailor information and advertising to your interests based on e.g. the content you have visited before. (Currently we do not use targeting or targeting cookies.
Advertising: Gather personally identifiable information such as name and location

This website will:

Essential: Remember your cookie permission setting
Essential: Allow session cookies
Essential: Gather information you input into a contact forms, newsletter and other forms across all pages
Essential: Keep track of what you input in a shopping cart
Essential: Authenticate that you are logged into your user account
Essential: Remember language version you selected
Functionality: Remember social media settings
Functionality: Remember selected region and country
Analytics: Keep track of your visited pages and interaction taken
Analytics: Keep track about your location and region based on your IP number
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Analytics: Increase the data quality of the statistics functions

This website won't:

Remember your login details
Advertising: Use information for tailored advertising with third parties
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Advertising: Gather personally identifiable information such as name and location

This website will:

Essential: Remember your cookie permission setting
Essential: Allow session cookies
Essential: Gather information you input into a contact forms, newsletter and other forms across all pages
Essential: Keep track of what you input in a shopping cart
Essential: Authenticate that you are logged into your user account
Essential: Remember language version you selected
Functionality: Remember social media settings
Functionality: Remember selected region and country
Analytics: Keep track of your visited pages and interaction taken
Analytics: Keep track about your location and region based on your IP number
Analytics: Keep track of the time spent on each page
Analytics: Increase the data quality of the statistics functions
Advertising: Use information for tailored advertising with third parties
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