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New Dyce Medical Practice

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Self Help & Wellbeing
Online Forms

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Contact Us

HRT Review Form

Please only complete this form if you have been requested to do this by a member of our clinical team.

Once you have completed the form it will be reviewed by our clinical team and we will make contact with you thereafter.

Last Updated: 14/03/2024

HRT Review Form

Name *

Date of Birth *

Telephone Number *

What is the name of your HRT? *

Why do you take HRT? *

Early Menopause (before age 45)

Menopausal symptoms

Please record your BP *

Please record your weight (Kg) *

Please record your height (cm) *

Do you smoke? *

Yes

If Yes, how many do you smoke?

Do you have any blood clotting disease/previous DVT/Pulmonary embolus? *

Yes

Do you have any family history of blood clotting abnormalities or blood clots? *

Yes

Do you have/or do you have any family history of breast cancer under the age of 50? *

Yes

Have you had any gynaecological procedures? *

Yes

If yes, what type of procedure did you have?

Have you got a Mirena Coil? *

Yes

If yes, how long have you had it for?

Do you have any other concerns related to HRT or your HRT medication?

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