HRT Questionnaire

Section

Questionnaire

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

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

Please provide the following information

In KG
Smoking status:
Would you like help to quit smoking?

Blood Pressure