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HRT Review/Repeat Prescription Request

HRT Review/Repeat Prescription Request Form
Please use format day/month/year e.g. 12/05/1979
Do you also have a Mirena Coil?

General Health questions

Do you smoke?
Do you drink alcohol?

Blood pressure

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).

How would you describe your activity level

Bone Health

Have you had any broken bones (in adulthood)?
Has either parent had a broken hip?
Are you currently taking any steroids, (or taken them for longer than 3 months in the past?
Have you been diagnosed with any of the following:

Sexual/Reproductive Health

Have you had surgery to remove your:
Please use format day/month/year e.g. 12/05/1979
Have you noticed any of the following:

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.