Patient HRT Medication Review Questionnaire

Dear patient,

Only complete the following questionnaire if requested by the GP as part of your routine HRT review.

Please do not use this form for any other medical queries either routine or urgent.

If you are experiencing any of the following symptoms contact the surgery to make an appointment with the GP.

Painful swelling of leg
Weakness or numbness of the arm or leg
Sudden problems with your speech or sight
Difficulty breathing
Coughing up blood
Pains in your chest, especially if it hurts to breathe in
Unexpected vaginal bleeding
Persistent irregular vaginal bleeding
Breast lump, persistent breast pain, or nipple changes
Abdominal pain, discomfort or bloating
Weight loss that is not intended.

Complete all questions on this form.

Useful website resources

www.menopausematters.co.uk

www.onstella.com

thebms.org.uk (British Menopause Society)

Patient HRT Medication Review Questionnaire

Are you completing this form on behalf of

What is your relationship to the patient?

About the patient

Your first name

Your surname

Your address

Post code

Your date of birth

Your landline telephone number

Your mobile telephone number

Your email address

This email address maybe used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see the response you sent.

Are you happy for us to contact you by SMS text messaging or email?

HRT Medication requested

Length of time on HRT

When was your last period?

Have you had a hysterectomy?

Do you have a current Mirena coil fitted?

If you answered "yes" wen was it fitted? If you answered "no" type in "NA"

Are you currently using contraception? If yes, please state which method of contraception you are using.

Is HRT helping your symptoms?

Have you experienced any persistent unexpected bleeding, or increased bleeding?

Have you experienced any side effects since you started HRT?

Have you considered reducing or stopping your HRT?

Jean Hailes Questionnaire

Greene Climacteric Scale

The Greene Scale provides a brief measure of menopause symptoms. It can be used to assess changes in different symptoms, before and after menopause treatment. Three main areas are measured: 1. Psychological (Items 1-11) 2. Physical (Items 12-18) 3. Vasomotor (Items 19-20)

Please indicate the extent to which you are bothered at the moment by any of these symptoms by choosing he appropriate statement.

1. Heart beating quickly or strongly

Feeling tense or anxious

Difficulty in sleeping

Excitable

Attacks of anxiety, panic

Difficulty in concentrating

Feeling tired and lacking in energy

Loss of interest in most things

Feeling unhappy or depressed

Crying spells

Irritability

Feeling dizzy or faint

Pressure or lightness in head

Parts of body feel numb

Headaches

Muscle & joint pains

Loss of feeling in hands & feet

Breathing difficulties

Hot flushes

Sweating at night

Loss of interest in sex

Greene scoreTo be calculated by practice staff

Your health details

A blood pressure reading is required before issuing your prescription. Please supply a blood pressure reading using a home BP reading machine or make an appointment with the treatment room for a blood pressure check.

Current body weight in Kilograms

Current height in centimetres

Blood pressure

Systolic (Higher)

Diastolic (Lower)

General Health Check

Do you regularly check your breasts?

Are you up to date with your mamograms?

Which new medications or health supplements have you started since taking your last HRT prescription?

Have you been diagnosed with any new health conditions since we last issued your HRT?

Have you ever had any blood closts?

Have you ever had a heart attack or stroke?

Have you ever had breast or endometrial cancer?

Have you ever had liver or gallbladder disease

Do you have any family history of the following (Tick all that applies)

Blood clots (e.g. deep vein thrombosis or pulmonary embolism)

Breast cancer

Endometrial cancer

Heart attack

Stroke

None of the above

Smoking Review

Do you currently smoke?

Have you smoked in the past?

How many cigarettes do you smoke in a day?

Alcohol Consumption

How often do you have a drink containing alcohol

How many units of alcohol do you drink in a typical day when drinking?

How often have you had 6 or more units if female or 8 or more if male, on a single occasion in the last year?

Declaration

I confirm that the information provided is accurate to the best of my knowledge

I confirm that I am aware of how to take my HRT

I confirm that I am aware of the potential risks associated with HRT use and have read this website wellspring+ https://wellspring.health/hrt/

I confirm that I can book a routine appointment to discuss any further concerns I have with my HRT treatment

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Park Medical • Great James Street Health Centre, Great James Street, Derry, BT48 7DH.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.