Total Patient Triage

Fairbrook Medical Centre now uses a Total Patient Triage system. This allows us to be able to prioritise patients by clinical need and navigating patients to the most appropriate clinician or pathway.

Need help with a non-urgent medical or admin request? Contact us online.

HRT Review/Repeat Prescription Request

HRT Review/Repeat Prescription Request Form
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
Please use format day/month/year e.g. 12/05/1979

Your Health Details

Please use format day/month/year e.g. 12/05/1979
Have you had a hysterectomy?
Do you have a Mirena Coil fitted?

Blood pressure

Blood Pressure reading is required before issuing your prescription. A BP machine is available at the surgery reception.

Your reading is made up of 2 numbers and is measured in millimetres of mercury millimetres of mercury(). Enter the highest number first. This is the highest level your blood pressure reaches when your heart beats (systolic). Then enter the lower number. This is the lowest level your blood pressure reaches when your heart relaxes between beats (diastolic).

Health Checks

Have you been experiencing side effects since you started HRT?
Have you experienced any persistent unexpected bleeding, or increased bleeding?
Vaginal discharge or vaginal discharge different to normal?
Pain on intercourse?
Frequent urine infections(more than 3 a year)?
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?
Any change in medications since your last review?
Have you been diagnosed with rheumatoid arthritis/menopause <45/chronic liver disease/diabetes type 1/malabsorption/malnutrition/osteogenesis imperfecta

Lifestyle

Do you drink alcohol?
Please calculate number of units you drink using the online alcohol unit calculator (opens in new tab).
How often have you had 6 or more units on a single occasion in the last year?
What is your smoking status?
Do you use an e-cigarette?

Disclaimer

If you are unable to answer yes to the below statements you will not be able to submit this review form and will need to book a telephone consultation to discuss this before the next repeat prescription is dispensed.
I confirm that this is a repeat prescription request
I confirm that I am aware of how to take my HRT

Please read the information on HRT treatment risks on the Wellspring+ website (opens in new tab).

I confirm that I am aware of the potential risks associated with HRT use and have read the information on Website wellspring+
I confirm that any medication prescribed for me is for my personal use only and that I have responded honestly and provided complete and accurate information
I am aware that I can book an appointment to discuss any further concerns I have with my HRT treatment
I confirm that any medication prescribed for me is for my personal use only and that I have responded honestly and provided complete and accurate information

Should you have any requests about your HRT, please call the surgery and book a telephone call with a clinician

Privacy Policy

This form collects your name, date of birth, email, 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 manage your submitted data.