Hormone Replacement Therapy (HRT) Review Form

Hormone Replacement Therapy (HRT) Review Form

If you have been asked by the Surgery to submit an HRT Review Form, please complete and submit this questionnaire.  

 

Please remember that HRT does not provide any contraceptive effect. If you are under the age of 55 and have never been sterilised or had a hysterectomy, you may be at risk of unintended pregnancy if you are not using adequate contraception. 

 

 

PLEASE DO NOT SUBMIT THIS FORM IF YOU HAVE NOT BEEN ASKED TO DO SO.  Unsolicited forms sent to the Practice will not be processed and will be deleted automatically.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Please Answer all of the Following Questions

    Are you happy with your current HRT treatment?
    Do you currently smoke cigarettes, or have you smoked in the last 12 months?
    Do you ever vape?
    Have you been diagnosed with any of the following conditions at any point in the past?
    Have you ever had any breast abnormality, detected either through breast screening or self-examination?
    Do you have any unusual or unexpected vaginal bleeding? This could be bleeding between your periods, bleeding after sex, or periods that are continuing for longer than usual.
    Are you currently using any weight-loss injections? This includes drugs like Mounjaro (tirzepatide), Wegovy (semaglutide) and Byetta ( exenatide).
    Do you have a hormonal coil fitted to provide the progesterone component of your HRT? These coils have various brand names, like Mirena, Levosert, Kyleena, Jaydess and Benilexa.
    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.
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Page last reviewed: 12 June 2026
Page created: 12 June 2026