HRT Initiation Form - Oak Tree Surgery

Contraception / HRT medication request Form

For new starters and repeat issues, please complete this form and a member of the nursing team will contact you in due course.

We will not be able to process this form and make an appointment without an up to date blood pressure reading.

If you are not able to take a weight/height or BP measurement at home or at the pharmacy you can drop into the surgery between 8.30 and 6pm Monday – Friday and use the pod (ask at the front desk)

We will be in touch within 5 working days from the time you submit your form.

Name

Address

Post Code

Phone Number

Date of birth

Blood Pressure

Height

Weight

Do you smoke?

Yes
No
Ex-Smoker

This form is for patients who are not yet taking HRT but feel they have menopausal symptoms and would like to discuss these with a doctor.

Please tell us the symptoms you have that you feel may be due to the menopause

Please tell us about your periods - are they regular/irregular, heavy or light? When was your last period? (If you have been having very heavy periods/flooding, bleeding after sex or bleeding in between periods this may be due to other serious conditions and you need to make an appointment with the GP before you can continue with this form)

Are you taking any contraception? Do you feel you need contraception?

Do you have current or past breast, ovarian, endometrial or cervical cancer? Has anyone in your family suffered from these cancers?