HRT Questionnaire

Name Required

First Last

Date of Birth Required

Please give us your up to date body weight and height Required

What is your smoking status? If you smoke how many a day? Required

Name of current HRT using Optional

Any new medications since last review? Optional

Is HRT helping? Optional

Duration of HRT Optional

Any side effects? Optional

Any vaginal dryness or discomfort? Optional

Are you up to date with your breast screening? Optional

Are you up to date with your cervical screening? Optional

Any new or unexpected vaginal bleeding/spotting? Optional

Any family history of breast cancer? Optional

Have you previously had a hysterectomy? Optional

Are you using any contraception currently? Optional

Are you looking for contraception advice? Optional

Are you considering stopping HRT? Optional

Any other comments in regards to HRT? Optional

Additional Information