HRT Review Questionnaire

Step 1 of 3

Patient Details

Name

First Last

NHS Number (If known) Optional

Date Of Birth

Contact Phone Number

Nominated Pharmacy

Email Address

Date Form Submitted

HRT Medication and Symptoms

Menopause – NHS

What is the name of the current HRT Medication that you are taking?

When do you next require a prescription?

Are you taking or using your HRT as prescribed?

Are you taking any new medication or over the counter medication since your last HRT review (including supplements)?

Have you experienced any new or worsening side effects since starting HRT?

How are you feeling in general since starting or continuing with HRT?

Are you still experiencing any menopause symptoms? (hot flushes, night sweats, mood changes, vaginal dryness, low libido)

Bleeding

Do you have a uterus? Please state if you have had a previous hysterectomy)

Do you still have periods?

Are you experiencing any unexpected vaginal bleeding or changes in your cycle?

If you are post-menopausal, have you had any bleeding at all?

Contraception

If you are under 55 and sexually active and at risk of falling pregnant, are you using contraception?

If yes, please state which contraception you are on or if you have a coil or implant fitted.

Do you need any advice on contraception while on HRT?

Risks

Benefits and risks of hormone replacement therapy (HRT) – NHS

Have you had any new diagnosis or hospital admissions in the past 12 months? (specifically, breast cancer, blood clots or heart disease)

Yes

Please provide further details

Do you have any family history of breast cancer, blood clots, stroke or heart disease?

Screening

Do you examine your breast regularly to detect for any lumps?

Did you attend your last mammogram if you have been invited?

NHS Cancer screening

If you have a uterus, are you up to date with your smear tests? (Every 3 years between the age of 25-49yrs then every 5 years until 64yrs)

NHS Cervical Screening

BP and lifestyle

Please record your blood pressure (you can check this at home or using the self check pod in reception) A short supply of HRT may be issued if we do not have a current reading.

NHS Blood Pressure

We have Health and Wellbeing Coaches who can support patients with weight management and health lifestyle planning. Please let us know if you would like to be booked with them.

What is your current weight?

What is your height?

Do you know what your BMI is?

Do you smoke?

On average, how many units of alcohol do you drink per week?

Forward Leeds Alcohol Service

Bone Protection and Risk of Fractures

As part of your HRT review, we’d like to check on your bone health. HRT can help protect your bones, especially around the time of menopause, but it’s important we assess any additional risk factors for osteoporosis or fractures.

Osteoporosis – NHS

Have you ever had a broken bone after a fall or injury?

Has either of your parents ever had a hip fracture?

Are you currently taking or have in the past steroid tablets (e.g prednisolone) for more than 3 months?

Do you have any of the following conditions? Rheumatoid arthritis, Thyroid problems, Coeliac disease, Diabetes, Kidney or liver condition

Have you ever had a DEXA scan (Bone density scan)?

Do you currently take any medication for bone protection?

Advice and Support

Is there anything you would like to discuss with the GP, Pharmacists or Nurse regarding your HRT? Optional

If you need to discuss any concerns before your review, please contact the surgery or go online to book an appointment using our online forms.

Are you happy to continue with your current HRT?

We may offer menopause group consultations or virtual webinars to support woman. Would you be interested in attending one? Optional

What happens after I have completed the questionnaire?

Your response will be sent directly to the practice to review once you click the submit button. Please allow 2 working days for repeat prescriptions to be issued. If you have passed your review date, please allow 7-10 days for our team to review your form and reauthorise your prescription (this may take longer if we require additional information or to arrange an appointment with you to discuss further). If you require your medication sooner, please contact reception to let them know you have completed the form online for your review.

Your responses indicate that your current HRT has been assessed as low risk	Once we have assessed all your responses and current risk factors, our GP, Pharmacist or Nurse will prescribe a further supply for the next 12 months (if a shorter supply is indicated, we will inform you). If you have provided us with a nominated pharmacist, then we will send your prescription across to them. We will send you a message when this has been done
Your responses indicate that it may be unsafe to continue prescribing HRT or we need to discuss the risks and benefits to continue prescribing your medication.	One of our GP’s or Pharmacists will contact you to discuss your responses and risk factors before issuing any further prescriptions. This is to ensure your current HRT is safe to continue