HRT Medication Review

HRT Review Form

This form is intended for patients who are on hormone replacement therapy (HRT) and are due a medication review.

Information provided is CONFIDENTIAL and will provide the reviewing practitioner key information to ensure the safe prescribing of HRT.

Please ensure you complete each question and read the entire document including the additional information on risks associated with HRT.

Reason for completing form: *

I am happy with my HRT medication and want to continue taking it

I am having issues with my HRT medication and/or I want to change my medication

I want to STOP taking HRT medication

Your Details

Full Name *

Date of Birth *

Home Address *

Phone Number *

Email Address *

The Practice may need to contact you to discuss your form. You might be contacted by phone, SMS, or email. *

I consent to the practice contacting me by phone, SMS and/or email.

This form requests your information in order to confirm you are registered with the practice and to allow the practice to contact you. 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.

Your physical measurements

In order to review your HRT medication, we need an accurate measurement of your height, weight, and blood pressure.

We cannot process this form without a blood pressure reading. If you don't have a BP machine at home, please use the Health Station in our waiting room. You can also measure your BP in some pharmacies.

Please provide your height (cm) *

Please provide your weight (kg) *

Please provide your blood pressure reading: *

Your medical history

Reviewing your HRT medication

Testosterone

The questions in this section are only for patients taking testosterone. If this does not apply to you, please skip this section or select 'not applicable'.

If you are using testosterone, have you experienced any of the following:

Increased facial or body hair (common)

Male pattern hair loss (less common)

Acne or greasy skin (less common)

Deepening of voice (rare)

Enlarged clitoris (rare)

Not applicable

If you are using testosterone, please tick if any of the following statements apply:

I am currently taking warfarin

I compete in sport at a professional level

Not applicable

Safety and Screening

Do you smoke? *

Yes

I used to smoke but I don't anymore

If you answered 'yes' to the previous question, how many cigarettes do you smoke per day?

If you used to smoke, when did you stop?

If applicable, are you up to date with breast screening? *

Yes

Not applicable

If applicable, are you up to date with cervical screening? *

Yes

Not applicable

Risks and Side Effects

Like any medicine, HRT can cause side effects but it's common to have no side effects or only mild ones.

Side effects can include: headaches, breast tenderness, unexpected vaginal bleeding, nausea, mood changes, leg cramps, mild rash or itching, diarrhoea, hair loss or growth, acne, and more.

While HRT can be effective at relieving menopause symptoms, it can also increase your risk of developing certain conditions including: osteoporosis, loss of muscle strength, breast cancer, blood clots, or stroke.

Please visit the NHS website for more information on HRT benefits and risks:
https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/

Have you read and understood the information above? *

I confirm I have read and understood the information above detailing the risks associated with HRT

What happens next?

Thank you for taking the time to complete this form. The information you have submitted will be reviewed by a clinician. If they have any concerns, they will contact you by phone. Alternatively, they may issue a prescription to your preferred pharmacy. If you have provided a mobile number, we will notify you when your prescription has been issued.

Please click the 'Submit Form' button below to save your response.

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Page last reviewed: 01 August 2025
Page created: 01 August 2025

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HRT Medication Review

HRT Medication Review

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