Hormone Replacement Therapy (HRT) Review "*" indicates required fields Please complete this form to help us review your HRT. HRT provides physical and psychological benefits during the menopause but also comes with risks. Please read this NHS article about the risks of HRT Starting and continuing HRT is a decision made by you and your GP based on your individual case however here is a very simple rule of thumb: < 50 years old – we would recommend you continue HRT 50 – 60 years old – we would recommend you consider consider the risks vs benefits and stop if your symptoms allow > 60 years old – the risks are usually greater than the benefits and you should consider stopping Name* First Last Date of Birth* DD slash MM slash YYYY Phone number to contact you with*I have read the above information on HRT and considered the risks* Yes No, I am already aware of the risks Blood pressure (Please either do this at home or book with our nurse to have it done)* Weight (Please either do this at home or book with our nurse to have it done)* Have you ever had a blood clot, stroke, heart attack or breast cancer?* YES NO Do you smoke?* YES NO Have you had a hysterectomy? (Removal of your womb)* YES NO Do you have a coil in your womb?* YES NO How are you?* Happy with my current HRT and would like to CONTINUE for the next year Please stop my HRT I would like to discuss my HRT Comments Optional This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data.Consent* I agree to the privacy policy.© 2022 Kristian TurnbullCAPTCHA Optional
