Hormone Replacement Therapy

Hormone Replacement Therapy

Personal Details

Name
Name
First Name
Last Name
Address
Address
City
County
Postcode

Further Details

Are you younger than 50 years of age?
Have you had a hysterectomy?
Have you had a Mirena coil (intrauterine system, IUS) fitted?
Have you measured your blood pressure?
Have you been experiencing side effects since you started HRT?
Have you considered reducing or stopping your HRT?
Have you experienced any persistent unexpected bleeding, or increased bleeding?
Do you regularly self-check your breasts?
If applicable, are you up to date with your mammograms?
Have you ever had any bloods clots? (e.g. Deep Vein Thrombosis or Pulmonary Embolism)
Have you ever had a heart attack or stroke?
Have you ever had breast cancer or endometrial cancer?
Have you ever had liver or gallbladder disease?
Do you have a family history of any of the following? Please select any that apply
Are you currently using contraception?
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