Prescription team: Medication & HRT review

We review any regular medication on a repeat prescription annually and wherever possible the doctor will do this without you having to attend the surgery.

If you have been advised by the surgery that your medication review is due please use this form. Ensure that you complete any outstanding blood test requests prior to filling out this form. You will know if you need to have a blood test by reading the prescription note or text message you were sent by us.

Certain medications need regularly monitoring (often yearly). This may include

Blood tests
Blood pressure checks

You will be contacted by our team if this is required.

Hormone replacement therapy (HRT) is a treatment to relieve symptoms of the menopause. It replaces hormones that are at a lower level as you approach the menopause.

The main benefit of HRT is that it can help relieve most of the menopausal symptoms, including: hot flushes, night sweats, mood swings, vaginal dryness and reduced sex drive.

Many of these symptoms pass after a few years, but they can be unpleasant and taking HRT can offer relief for many women.

Whilst the benefits of HRT often outweigh the risks, some types of HRT can increase your risk of breast cancer and blood clots. It is important to remain vigilant for signs of breast cancer & we encourage you to attend breast screening when invited.

To ensure your medication is prescribed safely and you are aware of all this information we review your prescription every 12 months.

If your review is now due please complete the following form and fill in as much information as possible. Some of this information will already be included in your medical records but this is a good opportunity to update any changes

Information page on HRT

HRT & Risk of Breast Cancer

Infographic on the risks of HRT (EXTERNAL PDF LINK)

Antidepressant review mood questionnaire calculator

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 7 working days to complete. Please DO NOT call before 7 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Prescription team: Medication & HRT review

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile)

Do you have any concerns or side effects from your medication?

If yes - Please explain what side effects or issues you have experienced

Do you know when and how to take your medication?

Please record your most recent home/hospital/pharmacy blood pressure:It is really important to try and get a home reading as this will help speed up the process. If no reading is given you will need to attend the practice to have your blood pressure taken.

Are you on any antidepressant medication?

Please state what score you calculated on the mood questionnaire PHQ-9 (LINK ABOVE). Please note that if your mental health is currently significantly impact and you are concerned for your well-being you must contact the crisis team on 0300 200 0011 and select option 1 or 999.

If you are on antidepressants, can you please select the option which best applies to you?If you are struggling with your mental health please contact the practice or if out of hours or in an emergency call the CRISIS team: 0300 200 0011 and select option 1.

Do you take an over the counter, herbal remedies or specialist medication? If no write: NO. If yes, please state the name and dose of these medications.

HRT Review

Please give details about your current HRT regime. Whilst this will be on your medical records it can be important to clarify exactly what type of HRT you are using

Are you happy with your current HRT?

If you would like to change to a different HRT regime do you know what type you would like to change to?

Have you had any problems finding it in stock?

Have you had a total hysterectomy?A total hysterectomy is where your uterus and cervix have been removed

Do you have a Mirena coil?

If you have a Mirena coil and know its insertion date please enter this here:

Do you know when your last period was? Please select the closest date possible

If you are having periods are they still fairly regular? If not, please describe what your cycle is like:If you are no longer having periods or you have a Mirena coil please indicate this here

Have you noticed any unusual or unexpected bleeding? If yes, please give details. If no state 'no'. This might include unusual bleeding in between regular periods, bleeding after sex or bleeding more than 12 months after your last period

Is your smear test up to date?Please note those aged 25 to 49 should have a smear test every 3 years. For those aged 50 to 64 it is every 5 years. While those over 65 will only need one if 1 of your last 3 tests was abnormal.

Do you have a history of breast cancer or does it run in your family?Out of 1,000 women taking HRT between the ages of 50-59, there will be an extra 4 cases of breast cancer diagnosed every 5 years. If you use oestrogen only HRT there are 4 fewer cases diagnosed.

Do you have a personal or family history of ovarian cancer?A recent study found that for every 1,000 women taking HRT for 5 years, there will be 1 extra case of ovarian cancer

Is there any personal or family history of blood clots?It is thought that the risk of developing a blood clot is 2 to 4 times higher than normal for women taking HRT tablets. But as the risk of menopausal women developing blood clots is usually very low, the overall risk from taking HRT tablets is still small. It is estimated that for every 1,000 women taking HRT tablets for 7.5 years, fewer than 2 will develop a blood clot. Please note that there is no increased risk of blood clots when using HRT patches or gels

Have you had a heart attack or stroke or do you have a first degree relative (parents, siblings or children) who has had a heart attack or stroke?The evidence shows that HRT does not significantly increase the risk of cardiovascular disease (including heart disease and strokes) when started before 60 years of age. Oestrogen-only HRT is associated with no, or reduced, risk of heart disease. Combined HRT is associated with little or no increase in the risk of heart disease. Taking oestrogen tablets is associated with a small increase in the risk of stroke, but the risk of stroke for women under age 60 is generally very low, so the overall risk is still small

If you have a personal or family history of any of the above conditions please give more details here:

What is your blood pressure?Your blood pressure should be checked every 12 months whilst you are taking HRT. Please record it here. Blood pressure machines can be bought from pharmacies, online retailers and most supermarkets. If you are not able to check it yourself please arrange an appointment with one of our health care assistants.

Do you drink alcohol - if yes, how many units do you drink each week?If you drink more than 2 units of alcohol each day, out of 1,000 women aged 50-59 there will be an additional 5 cases of breast cancer diagnosed every 5 years.

Do you smoke?If you are a current smoker, out of 1,000 women aged 50-59 there will be an additional 3 cases of breast cancer diagnosed every 5 years.

Do you know your height and weight? Please record them here in either metric or imperial unitsIf you are overweight or obese (your BMI is equal or greater than 30) out of 1,000 women aged 50-59 there will be an additional 24 cases of breast cancer diagnosed every 5 years.

Do you exercise regularly?If you do at least 2.5 hours of moderate exercise each week, out of 1,000 women aged 50-59 there will be 7 FEWER cases of breast cancer diagnosed every 5 years.

Would you like to discuss contraception?Whilst a Mirena coil offers contraception other methods of HRT do not.

Would you like to continue your current HRT regime?If you would like to change to a different regime we will call you to discuss this further

If we are able to directly issue your prescription which chemist would you like to collect it from (name & postcode)?

I confirm that:

The information provided is accurate to the best of my knowledge

I understand the risks associated with HRT

I understand HRT is not a form of contraception (with the exception of the Mirena coil as long as it is within date)

Please note that if you are a diabetic you will need to have the following tests done annually

- Foot check examination

- Blood pressure

- Urine test (White top bottle; can be obtained from reception)

- Blood test

To get this done please contact reception to arrange an appointment and ensure you mention you require an appointment for all the above.

Have you ever had a mammogram? If so please let us know the date and the outcome

I confirm I am happy to accept the risks associated with using HRT.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.