HRT Questionnaire

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

HRT Questionnaire

HRT Questionnaire


Blood Pressure and Weight

Please arrange and submit readings on this form. Your medication can only be re-authorised for a further 12 months once these readings are received by the practice.

If you are unable to check your own blood pressure or weight, please access your local pharmacy or make an appointment with a healthcare assistant to take your readings before submitting this form.

Unit of measurement: *


Smoking status:
Would you like help to give up smoking?

Smoking Cessation services are available on 0800 0854 113.

Is your HRT managing your symptoms as expected? *
Do you have any concerns? *

Bleeding Pattern with HRT

Do you ever bleed? *
Do you have a monthly bleed? *
Do you have erratic bleeding? *
Have you had a change in your normal bleeding pattern? *

Cervical Smear

If you are under the age of 65 years, please ensure your smear is up to date. You will receive an invitation letter when this is due.

Breast Screening

Do you attend for mammograms when invited? *

You can register to continue breast screening beyond the age of 70 years by contacting the local breast screening unit on 01603 287777.

Are you breast aware? *

Contraception (if you are under 55)

Are you using a method of contraception?

Continuing on HRT (if you are over 60)

The safety of HRT largely depends on age. Women younger than 60 years should not be concerned about the safety profile of HRT. To continue HRT beyond this age, the benefit should outweigh the risk. Further information regarding this can be found at:

If wishing to continue it is recommended that you are on the lowest dose possible to maintain wellbeing, with delivery via a patch or gel being preferable to a tablet. It may be beneficial to speak to a nurse to discuss further.

I have read the guidance regarding continuing on HRT beyond the normal age of menopause and consider that for me the benefit outweighs the risk:

Please book to discuss with a women’s health nurse.