HRT Questionnaire

If you have been advised by the surgery to complete a HRT Questionnaire, please use this form.


HRT Questionnaire

HRT Questionnaire

Please use format: DD/MM/YYYY
Please use format:


Are you currently prescribed HRT? *

As you are not currently prescribed HRT, please arrange a telephone consultation with a GP using our Consulting Room and do not continue with this form.

Prescribed HRT

Do you currently have a MIRENA coil fitted? *
Have you had a hysterectomy? *
Do you have any vaginal bleeding? *
Please specify: *
Do you bleed after having sex? *
Do you experience any of the following?
Do you experience any of the following side effects?

Please provide the following information

Smoking status:
Would you like help to quit smoking?

Blood Pressure