HRT Form

Full Name

Date of Birth

Age at next birthday?

Address

Contact Number

Please enter your BP reading taken within the last 6 months

Would you like your prescription sent to your nominated pharmacy?

Yes
No (I will collect from the Waterfront Medical Centre)

Do you have any known drug allergies?

Yes

No

If yes, please state below. (optional)

Please specify which HRT you are currently using?

Is the HRT helping with your symptoms?

Yes

No

Are you experiencing any undesired side effects?

Yes

No

If yes, what side effects are you experiencing? (optional)

Is there any change to your health since your last HRT check?

Yes

No

Have there been any changes to your medication since your last HRT Check?

Yes

No

Do you have any vaginal dryness or discomfort?

Yes

No

Do you have any concerns about vaginal bleeding?

Yes

No

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.

Yes

No

Do you bleed between periods?

Yes

No

Do you require contraception?

Yes

No

Are you attending recommended screening programmes? (Mammograms for over 50 / Smears over 25)

Yes (mammograms)
Yes (cervical smears)
No

Have you had a hysterectomy?

Yes

No

Do you have a IUS/Mirena coil?

Yes

No

If yes, when was this fitted? (optional)

What is your current weight?

If you have access to a BP machine please provide us with an up to date reading, alternatively, you can use the Practice BP machine in the reception waiting area.

What is your current blood pressure?

Do you smoke?

Yes

No

If yes, how many a day do you smoke? (optional)

Do you drink alcohol?

Yes

No

If yes, how many units a week? (optional)

Do you suffer from migranes (a migraine is a headache during which you feel sick, have to lie down or cannot look at light)

Yes

No

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)

Yes

No

What was the date of your last menstrual period?

Do you have any of the following conditions?

If yes, please provide further detail (optional)

This form collects your name, date of birth, 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.

Yes

Waterfront Medical Centre

Personal Details

Further Information

Consent