HRT Questionnaire

If you have been advised by the surgery to complete a HRT Questionnaire, please use this form.

HRT 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

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

Please provide the following information

Blood Pressure

Please confirm that you have read the HRT Information for Patients Leaflet by checking the box below: