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Mackenzie Medical Centre

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Appointments
New Patients
Prescriptions
Self Referral
Patient Record
Services
Health Advice
Patient Coffee Morning
Practice Policies
Practice News

Home
Online Services
Our Staff
Self Referral
Practice News
Opening Hours
Contact Us

HRT Review

Please complete this form as part of your HRT review ONLY if you have been asked to do so. Below you will also find links to further information.

You will need an up to date blood pressure reading before you complete the online details. If you do not have access to a home BP machine please make an appointment with the nurse.

General information about HRT

Alternatives to HRT

HRT and Breast Cancer - MHRA information leaflet

Last Updated: 16/04/2024

Your Details

First Name *

Last name *

Address *

Date of Birth *

Phone Number

Email Address *

HRT Review

Have you been diagnosed with any new health conditions since we last issued your HRT? (These could be any conditions but in particular: any breast or ovarian conditions, blood clots or a clotting disorder, cancer, heart disease, liver disease, migraines or diabetes) *

Yes No

Do you have a family history of breast cancer? *

Yes No

Have you had any new or unexpected vaginal bleeding/spotting? (Such as after sex, between periods or after 12 months of not having a period) *

Yes No

Have you had a hysterectomy? (A hysterectomy is where you’ve had surgery to remove your womb [uterus]) *

Yes No

Are you currently using contraception? (Please note, HRT does not act as contraception) *

Yes No

Do you require advice about contraception? *

Yes No

What is your smoking status? *

Current Smoker

Ex-smoker

Never Smoked

Are you able to provide a blood pressure reading? (As part of the review of your HRT we need an up-to-date blood pressure reading – please make a nurse appt if you do not have a BP machine) *

Are you able to provide a weight and height reading? *

Are you considering stopping your HRT? *

Yes No

Do you have a coil in? *

Yes No

If yes, please give details

How long have you been taking HRT? *

Are you having any side effects or problems from your HRT? *

Do you have any vaginal dryness or discomfort? *

Are you up to date with your breast screening (mammogram)? (A mammogram is a type of X-ray that looks for breast cancer. You should be invited to have a mammogram every 3 years between the ages of 50 and 71 unless you have been told otherwise by a healthcare professional) *

Yes

No

I'm not sure

Are you up to date with your cervical screening (smear test)? (Unless you have been told otherwise by a healthcare professional, you should be invited to have a smear test every 3 years between the ages of 25 and 49, every 5 years from age 50 to 64 and then over 65 if one of your last 3 smear tests was abnormal) *

Yes

No

I'm not sure

Privacy policy

This forms collects your name, date of birth, email address, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manager your submitted data.

I consent to the practice collecting and storing my data from this form. *

Yes No

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Further Information

Self Referral
Mental Health
Online forms
Carers Advice
Care Information Scotland
CFC Inhalers
Data Protection Notice
NHS Inform
Pregnancy Care in Scotland
Patients' Rights and Responsibilities
Practice Policies
Suggestions & Complaints

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