Ffurflen Gais am Feddyginiaeth atal cenhedlu / HRT

Rydym wedi creu'r ffurflen hon i wella cyfleustra cleifion a mynediad at feddyginiaeth atal cenhedlu neu HRT. Cwblhewch ef yn llawn i'w adolygu gan y tîm clinigol.

Enw

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?