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  • New Computer System Update

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

https://www.menopausematters.co.uk/

https://www.onstella.com/

https://thebms.org.uk/ (British Menopause Society)

 

Patient HRT Medication Review Questionnaire
About the patient

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.

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.

To 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.

Blood pressure
General Health Check
Do you have any family history of the following (Tick all that applies)
Smoking Review
Alcohol Consumption
Declaration

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.

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.


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Park Medical

Great James Street Health Centre, Great James Street, Derry, BT48 7DH

  • 028 7137 8500
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