HRT Medication


PLEASE NOTE: 

To process this form the practice will require an up-to-date blood pressure reading within the last 6 months. Please DO NOT continue with this form if you do not have an up-to-date BP.


This form is for on-going HRT medication requests only. For new HRT requests please make an appointment with the GP. 

Please complete this form and contact the Practice after 72 hours to check if your prescription is ready (this does not include weekends/bank holidays)

Last Updated: 21/04/2023

  • HRT Medication Review

    ARE YOU CURRENTLY USING HRT?
    WOULD YOU LIKE YOUR PRESCRIPTION SENT TO YOUR NOMINATED PHARMACY?

  • IF YOU HAVE NOT BEEN ON HRT MEDICATION, PLEASE COMPLETE SECTION 1&3

  • IF YOU HAVE BEEN ON HRT MEDICATION PLEASE COMPLETE SECTION 2&3

  • HRT QUESTIONNAIRE - PART 1

    Please complete this section if you have NOT been on HRT medication before.

    DO YOU FEEL THAT YOUR SYMPTOMS ARE RELATED TO THE MENOPAUSE? (optional)
    Could you be pregnant? (optional)
    Have you recently changed your sexual partner? (optional)
    Have you found out about the benefits and potential long-term risks of HRT? (optional)
    Do you have any vaginal dryness or discomfort? (optional)
    re you attending recommended screening programmes? (Mammograms for over 50 / Smears over 25) (optional)
    Do you have a regular monthly period? (optional)
    Are you sexually active? (optional)
    Do you bleed after sexual intercourse? If you answer yes for this questions, please contact the Practice to book a telephone appointment with a GP (optional)
    Do you bleed between periods? (optional)

  • HRT Questionnaire - Section 2

    If you are already prescribed HRT medication, please complete this section

    Is the HRT helping with your symptoms? (optional)
    Are you experiencing any undesired side effects? (optional)
    Is there any change to your health since your last HRT check? (optional)
    Is there any changes to your medication since your last HRT Check? (optional)
    Do you have any vaginal dryness or discomfort? (optional)
    Do you have any concerns about vaginal bleeding? (optional)
    Do you bleed after sexual intercourse? If you answer yes to this questions, please contact the Practice to book a telephone appointment with a GP (optional)
    Do you bleed between periods? (optional)
    Do you need contraception? (optional)
    Are you attending recommended screening programmes? (Mammograms for over 50 / Smears over 25) (optional)

  • HRT Questionnaire - Part 3

    Have you had a hysterectomy?
    Do you have a IUS/Mirena coil?
    If yes to above question, when was this fitted? (optional)
    For example, 15 3 1984
    Do you smoke?
    Do you drink alcohol?
    Do you suffer from migranes (a migraine is a headache during whcih you feel sick, have to lie down or cannot look at light)
    If yes to above question, have you ever suffered from aura at any age? (an aura is a visual or sensory symptom in the hour before the headache starts) (optional)
    Please select if you have suffered from any of the following conditions

  • Consent

    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 Waterfront Medical Centre to contact you, and to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy for more information on how we protect and manage your submitted data. I consent to Waterfront Medical Centre collecting and storing my data submitted via this form.
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