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Lammermuir Medical Practice

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LMC Statement- Why is your GP practice now unable to do everything they once were?

New Patients
Appointments
Cancel an Appointment
Prescriptions
Services
Health Advice
Online Forms
Patient Record
LMC Statement- Why is your GP practice now unable to do everything they once were?

Home
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HRT Review

HRT Review

HRT Review

We perform annual reviews for woment taking HRT in order to ensure the medicine is still meeting your needs and that it is still safe to prescribe.

If you are having any problems with your HRT, would like to switch to a different type of HRT or have any questions, please do not use this form and contact the surgery to arrange an appointment.

Your Details

Name *

Date of Birth *

Phone Number *

Email Address *

HRT Review

To continue safely prescribing HRT, we need to ensure that you remain aware of the risks that may be present with HRT , please click on this link for more information:

Benefits and risks of hormone replacement therapy (HRT) - NHS

I confirm that I understand the risks of HRT *

Yes No

Please can you tell us what type of HRT you are taking, including the name and dose (eg tablets, patch or gel) *

Do you have a hormonal coil in place? This is usually the Mirena coil.

Yes No

For How long have you been taking HRT *

Do you have periods or bleeding with your HRT? *

Yes No

Does your HRT help you perimenopausal/menopausal symptoms? *

Yes No

Do you ever miss or forget to take your HRT? *

Yes No

Do you need contraception? HRT is not a contraceptive method. *

Yes No

Height *

weight *

Blood Pressure - please supply recent reading, we cannot issue a prescription without this. If you do not have a Blood Pressure monitor at home or are unable to do own Blood Pressure please contact reception. *

How many units of alcohol do you drink each week? *

0 units per week

1-7 units per week

8-14 units per week

15 or more per week

Don't know

Do you smoke? *

Yes

No I have never smoked

Ex-smoker

Do you have any new breast symptoms? *

Yes No

Have you had a hysterectomy? *

Yes No

Have you ever had breast cancer? *

Yes No

Have you ever had any heart problems? *

Yes No

Have you ever had a stroke or mini stroke? *

Yes No

Have you ever had a blood clot? *

Yes No

Have any of your parents or siblings been diagnosed with a blood clot? *

Yes No

Having read the guidance at the top of this form, do you feel that, for you that the benefit of taking HRT outweight the risk? *

Yes No

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. *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 30 May 2025
Page created: 14 October 2022

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