HRT Questionnaire

If you have been advised by the surgery to complete a HRT Questionnaire, please use this form.

HRT information for patients

HRT Questionnaire - Westgate

Section

Questionnaire

Are you currently prescribed HRT? *

As you are not currently prescribed HRT, please arrange a telephone consultation with a GP using our Consulting Room and do not continue with this form.

Prescribed HRT

Do you have a MIRENA coil fitted? *
Have you had a hysterectomy? *
Do you have any vaginal bleeding? *
Please specify: *
Do you bleed after having sex? *
Do you experience any of the following?
Are your symptoms improving?
Are you happy to remain on your current treatment?
Would you like to discuss your symptoms and consider changing HRT?
Do you experience any of the following side effects?

Please provide the following information

Blood Pressure

If you do not have access to a home blood pressure device, please visit the practice and use the machine in our waiting area and then submit this form.

Please confirm that you have read the HRT Information for Patients Leaflet by checking the box below:

*
E.g. Monday AM/PM, Tuesday AM/PM
Please upload any relevant evidence in relation to this request.
Maximum upload size: 67.11MB