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Hormone Replacement Therapy

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at [email protected]

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

3. Are you female and over 45 years old?

4. Please tell us your height and your current weight

Foot
Inches
st
lb
Cms
KGs

Your BMI is: 0

5. Would you like information on weight management?

6. Do you smoke?

6b. Would you like information on stopping smoking?

7. Do you drink alcohol?

7b. Would you like information on safe alcohol use?

8. Are you pregnant, breastfeeding or trying to become pregnant?

8b. Please tell us how many weeks pregnant you are:

9. What is your blood pressure?

10. Have you been diagnosed of menopause by your GP?

11. What symptoms of the menopause do you have?

12. When was your last period?

13. Have you had your womb (uterus) removed? Also known as a hysterectomy?

14. Have you used/ currently using hormone replacement therapy or contraceptives (incl. coils, Implants, Pills)?

14b. What is the name of the HRT/contraceptives medication you have used/ using? If you are changing to a different HRT medication, please specify why? Have you experienced any side effects?

15. How long have you been using HRT?

16. Have you had a review with your GP about HRT Treatments in the last 12 months?

The Family Chemist recommends you discuss your HRT options with your doctor or The Family Chemist Clinician before starting your HRT treatment. You must see a GP once a year or more if you currently use HRT for an overall health check.

16b. Did the doctor have any concerns? Please provide more detail if the doctor had any concerns.

17. Have you experienced any unexpected vaginal bleeding in the last 12 months?

17b. Please provide more details. Have you seen your doctor regarding the unexpected vaginal bleeding?

18. Have you ever been treated or currently have the following cancers?

19. Do you have family history of breast, endometrial or ovarian cancer?

19b. Please specify which cancer and your relationship to the family member who had cancer?

20. Have you been diagnosed with any of the following health problems?

21. Have you had a cervical smear in the last 3 years?

21b. What was the outcome of the test?

22. Have you had a breast examination or mammogram in the last 5 years?

22b. What was the outcome of the test?

23. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

23b. Please provide more details:

24. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

24b. Please provide more details:

25. Are you allergic to any medicines or other substances e.g. peanuts or soya?

25b. Please provide more details:

26. Would you like us to pass on details of your treatment to your GP?

To ensure your treatment is safe we require you to allow us to share data with your GP. Please ensure your GP details are provided during registration.

27. I understand and accept that:

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] so we can talk through your options.

  • Unless otherwise indicated it is essential you complete you national screening program and have regular cervical, breast and bowel screening
  • Hormone replacement therapy (HRT) does not provide contraception.
  • HRT medication from The Family Chemist should not be used for Gender Reassignment.
  • Venous thromboembolism (VTE): Blood clots. These risks are increased when taking oral medication (although still small). Evidence suggests patches have no greater risk than patients not using medication.
  • Heart disease and stroke: HRT with oestrogen alone is associated with no or reduced risk of heart disease. Combined HRT (oestrogen and progesterone) carry little or no increase in the risk of heart disease. Risk of stoke in women under 60 is very low. Oral oestrogen (not patches) are associated with a small increase in the risk of stoke). HRT does not increase cardiovascular disease risk whens tarted in women younger than 60 years.
  • Breast Cancer: Oestrogen only HRT is associated with little or no increased risk. Combined HRT is associated with increased risk of breast cancer and is dependent on the duration of treatment (reduces after stopping HRT). The risk is slightly lower with cyclical compared to continuous HRT. Here’s some more information extracted from MHRA.
  • Check your breast regularly for lumps. Refer to this website to learn how to check your breasts correctly.
  • The numbers of extra cases of breast cancer above would approximately double if HRT was used for 10 years instead of 5. Manufacturers advice that you should avoid using HRT beyond 5 years due to lack of data on risk.
  • Endometrial Cancer: women who have not had hysterectomy and are postmenopausal are at increased risk of endometrial cancer if they take oestrogen only HRT
  • Ovarian Cancer: Increased risk is every small (0.4 increased risk per 1000 women compared to someone not taking HRT)
  • HRT medication should taken in the lowest possible dose and for the shortest period of time.
  • You should not start or stop using HRT if advised by your doctor.

28. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] so we can talk through your options.

  • You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
  • I will contact my GP if I experience serious side effects or if side effects persist beyond 3 months.
  • You have answered the questions honestly and accurately and the treatment is solely for your personal use.
  • You will read and understand the patient information leaflet supplied with your medication.
  • You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
  • You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
  • You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
  • You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

29. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.