HRT Review Patient Questionnaire

Dear Patient, As part of your upcoming 3-month/annual hormone replacement therapy review, we would ask that you complete this online questionnaire and a member of the team will be in touch.

Please read 'HRT Therapy Risks and Benefits' leaflet - nhsfife.org/media/upnv4a0w/hrt-therapy-risks-and-benefits.pdf

Last Updated: 05/12/2024

Review Type

1. Choose review type:

My annual HRT review

My 3-month review (only required if you have started HRT medications for the first time in the last 2-3 months).
Patient Details

Name

Address

DOB (If over 59years old then book ANP or GP appointment for a medication review)
For example, 15 3 1984

Day

Month

Year
Patient Health Information

Height: (Please only record a reading from the last 2 weeks).

Weight: (Please only record a reading from the last 2 weeks).

Blood pressure (please only record your most recent reading within the last 2 weeks). Date blood pressure taken and reading. *IF OVER 180/XX THEN CONTACT PRACTICE IMMEDIATELY*

Have you ever had a hysterectomy (removal of uterus) OR currently have a Mirena coil fitted?

Yes

No

Unsure

How long have you been on HRT?

Less than 1 year

1 to 2 years

Three or more years

Did you start on HRT whilst you were? (choose unsure if you do not know)

Menopausal

Peri-menopausal (meaning not yet fully achieved menopause).

Unsure

what HRT medication are you on?

Smoking Status?

0 cigarette/tobacco per day

1-10 cigarette/tobacco per day

>10 cigarette/tobacco per day

I do not wish to say

Never smoked

Alcohol Status

No alcohol/teetotal

1-14 units/week

14+ units/week

I do not wish to say

If you have a Mirena coil, what month and year was it inserted? (Patient note: Mirena Coils are only effective for up to 5 years and require removal or changing after this period – you may arrange this with your coil provider). Please enter the date or "unknown" or "not applicable" (optional)
Section B

Have you had any vaginal bleeding that has been unexpected, persistent or ongoing after 6 months of using HRT?

Yes - If yes, please book a face to face appointment with Nurse Practitioner or the GP. Please end the form.

No - If no, continue completing this form

Have you had any new symptoms, worries or concerns related to the Hormone Replacement Therapy?

Yes - If yes, please book a face to face appointment with Nurse Practitioner or the GP. Please end the form.

No - If no, continue completing this form

Have you had any blood clots (deep vein thrombosis or pulmonary embolism) since your last review?

Yes - If yes, please book a face to face appointment with Nurse Practitioner or the GP. Please end the form.

No - If no, continue completing this form

To the best of your knowledge, do you have any of the following?

Previous family history of clots

Uncontrolled high blood pressure

Migraines

On St John Wort Medication

Gall bladder disease

A new diagnosis since starting on HRT which I am unsure is compatible with HRT.

Are your symptoms well controlled on your current dose of Hormone Replacement Therapy (HRT) AND would you be happy to have a further one-year script of your current HRT?

Yes

No

I confirm that this is a repeat prescription request

Yes - If yes, continue completing this form

No - if no, please book a face to face appointment with Nurse Practitioner or the GP. Please end the form.

I confirm that I am aware of how to take my HRT

Yes - If yes, continue completing this form

No - if no, please book a face to face appointment with Nurse Practitioner or the GP. Please end the form.

I confirm I have read the HRT benefits and risks and would like to continue to use it.

Yes - If yes, continue completing this form

No - if no, please book a face to face appointment with Nurse Practitioner or the GP. Please end the form.

I confirm that any medication prescribed for me is for my personal use only and I have provided accurate information, including a recent blood pressure, weight and height.

Yes - If yes, continue completing this form

No - if no, please book a face to face appointment with Nurse Practitioner or the GP. Please end the form.

I am aware that I can book an appointment to discuss any further concerns I have with my HRT treatment.

Yes - If yes, continue completing this form

No - if no, please book a face to face appointment with Nurse Practitioner or the GP. Please end the form.

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HRT Review Patient Questionnaire

Review Type

Patient Details

Patient Health Information

Section B