Initiation of HRT Form

Initiation of HRT Form
Please use format day/month/year e.g. 12/05/1979
Symptoms of the Menopause
Please tick any symptoms you are currently experiencing.
Do you have a uterus?
Please use format day/month/year e.g. 12/05/1979
Are you currently using contraception?
Are your cervical smears up to date?
Do you have any of the following?
Have you had a recent mammogram?
Have you had any gallstones?
Have you had any liver disease?
Have you had any history of angina, heart attack or stroke?
Have you had any history of blood clots (DVT, PE)?
Do you have any of the following?

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.