HRT Review

This form is to be used for the following reasons:

  • If you would like to start a new HRT or switch to a different HRT (will also need to complete an e-consult)
  • If you want a repeat of your current HRT
  • If you have been advised by a clinician to complete this form

Once this form is completed it is passed to a clinician to review. Once issued you will receive a text to collect your prescription at your nominated pharmacy. Please ensure your nominated pharmacy is up to date – please call reception to do so.

You should get a response within a week, if you do not hear anything please call reception.

Patient resources

For information on HRT including types of HRT, risks and benefits and side effects please see these useful links:

HRT Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

HRT Review

Do you need a repeat of your current HRT?
Please use date format DD/MM/YYYY
Do you feel your current HRT medication is helping?
Please read information on HRT s/e and risks before continuing.
Are you aware of risk and benefits of treatment?
Please refer back to resources listed above.
Do you have any side effects of current drug treatment?

Please check your blood pressure (if you do not own an at home blood pressure monitor/scales, please call reception to book a blood pressure appointment with the Healthcare Practitioner):

/
Use date format DD/MM/YYYY
Do you have any irregular bleeds? (in women with a uterus, unscheduled vaginal bleeding is a common side effect of HRT within the first 3 months of treatment but should be reported at the 3 month review appointment, or promptly if it occurs after the first 3 months)
Symptoms (select all that apply):

Personal History

Do you have a history of breast cancer, ovarian cancer or womb cancer?
Do you have a history of/current blood clots (DVT)?
Do you have cardiovascular disease?
Do you have untreated high blood pressure?
Do you have any lactose intolerance?
Do you have liver disease?
History of or concerns of gall stones?
History of migraines?

Family History

Is there any family medical problems associated with cancer, venous thromboemolism, cardiovascular disease or migraine?

Additional Questions:

Are you pregnant? (it's still possible to get pregnant while taking HRT, so you should use contraception until 2 years after your last period if you're under 50, or for 1 year after the age of 50)
Do you perform regular breast examinations on yourself? Know your breasts - A guide to breast awareness and screening
Smoking status:
*
Sending