HRT Review - Seaside Medical Centre

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. *

I consent to the practice collecting and storing my data from this form.

Weight *

Height *

Blood Pressure *

Smoking Status *

Smoker

Ex-Smoker

Non-Smoker

Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?

Deep vein thrombosis (a blood clot in the veins of the leg)

Pulmonary embolism (a blood clot in the lungs)

Stroke or cerebro-vascular disease

Heart disease

Breast cancer

Have you been diagnosed with or experienced any of the following conditions in the past 12 months?

Are you currently taking any of the following medications?

Anti-epileptic medication

Rifampacin

St Johns Wort

Are you experiencing any of these symptoms? *

Hot flushes

Night sweats

Brain fog

Have you suffered from any abnormal or unexpected vaginal bleeding or bleeding after sex in the past 12 months? * *

Yes No

If you answered yes to the previous question you are advised to make an appointment with a GP to discuss this further. *

Have you a Mirena coil fitted *

Yes No

Have you undergone a hysterectomy within the last 12 months? *

Yes No

Have you had a bone fracture within the last 12 months? *

Yes No

Please tick to show that you are up to date with the following routine screening. *

Breast screening

Cervical screening

Have you started any over the counter medication within the last 12 months? *

Yes No

If you have answered yes to the above question please let us know what medication you are now taking? *

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. *

I consent to the practice collecting and storing my data from this form.

HRT Review Form

HRT Review Form

Further Information

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HRT Review Form

HRT Review Form

Further Information