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New Dyce Medical Practice

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Practice News
Join The Practice
Appointments
Prescriptions
Services
Patient Record
Self Help & Wellbeing
Online Forms

Home
Opening Hours
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Contact Us

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HRT Review Form

HRT Review Form

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.

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

No

If Yes, how many do you smoke?

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

Yes

No

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

Yes

No

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

Yes

No

Have you had any gynaecological procedures? *

Yes

No

If yes, what type of procedure did you have?

Have you got a Mirena Coil? *

Yes

No

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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Page last reviewed: 14 March 2024
Page created: 07 December 2023

Further Information

Care Information Scotland
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Pregnancy Care in Scotland
Data Protection & Privacy
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