Larne Medical Practice > Forms > Health Review Forms > Hormone Replacement Therapy Review Form

Hormone Replacement Therapy Review Form

If your HRT Review is due please complete this HRT Review form. Below there are links to information

You will need an up to date blood pressure reading before you complete the online details. This can be easily organised using a home monitoring machine or through local pharmacies and Gyms. Please record this before you complete the application.

General information

Alternatives to HRT

HRT
Enter Email
Please use format day/month/year e.g. 12/05/1979

Your Height and Weight

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

HRT Review

Are you happy with your current HRT? *
e.g. 120/70. Blood Pressure (can be checked by one of our admin team or Nurse)
Do you smoke? *
How would you grade your Activity Levels:
Please indicate if you experience or have noted any of these symptoms: (please provide details)
Flushes
Breast Changes
Episodes of bleeding
Mood Changes
Mammogram Advice
If you are over 40 – Please ensure you arrange a regular mammogram with Action Cancer
If you are 50 and over – Please ensure you attend when you are called for your routine mammogram by the NI
Breast Screening Unit
If you have ANY concerns about changes to your breasts please arrange an appointment
One of our clinicians will contact you on this number in the next couple of weeks.

Privacy Policy

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.
Please make sure you have answered all questions as we cannot issue your prescription unless they are.

Please be aware you MAY be called to attend for an appointment

Thank You

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