Eastwick Park HRT Annual Review Form

If you have no concerns and wish to continue the same HRT prescription, please complete this form fully as part of your annual monitoring.

If you prefer to discuss your HRT with a clinician, please book an appointment via the website.

If you answer yes to any of the following questions, please give details.

Eastwick Park HRT Annual Review Form

Name and Dose of current HRT

Do you take any other regular medication?
Do you have a Mirena coil?
Have you ever had a hysterectomy?
Do you think you need contraception?
Was your HRT started in hospital, or in a private clinic?
Since starting HRT, have you experienced any side effects?
Have you experienced any vaginal bleeding you were not expecting?
Do you regularly examine your own breasts?
Do you attend national breast and cervical screening programmes as per your age group?

Smoking Status

Do you smoke?

Online self referral for stopping smoking available from One You Surrey:
One You Surrey Stop Smoking Service - Helping Surrey to go Smokefree

Do you suffer from migraines?
Have you ever had a blood clot in your legs or lungs?
Have you had recent surgery requiring a general anesthetic?
Any previous / current cancer treatment?
Has a close relative ever had a blood clot in the leg or lung?
Has a close relative ever had breast cancer?

Blood Pressure

If your readings are either above 140 systolic (top number) or above 90 diastolic (bottom number), please repeat two more times.

mmHg (home measurements from reputed arm BP monitor are acceptable
mmHg
mmHg
*

You can find more information about the benefits and risks of HRT and the available types at: www.nhs.uk/hrt

The Women's health Concern webpage gives information on a wide variety of female health topics, including HRT: www.womens-health-concern.org/factsheets