HRT Review


Please only complete the following questionnaire if requested by your GP practice as part of your routine HRT review.

This questionnaire is for a routine review of your HRT. If you are experiencing any of the following ring your GP immediately:

  • Painful swelling of your leg
  • Weakness or numbness of an 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
Have you had a hysterectomy?
Have you had a Mirena coil fitted?

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?
Are you up to date with your mammograms?
Have you ever had any blood clots? (eg. 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 any family history of any of the following? (Please select all that apply)
Are you currently using contraception?


Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *


Do you smoke?
Do you use an e-cigarette?
Would you like help to quit smoking?

For more information, please visit NHS Smokefree.

Further Questions