New Patient HRT Request

Patient Details

Please use date format: DD/MM/YYYY

Symptom Checker

Hot flushes: *
Night sweats: *
Sleep problems: *
Fatigue (extreme tiredness): *
Joint pains: *
Palpitations: *
Brain fog: *
Mood swings: *
Not functioning at work, home, in relationships: *
Urinary problems: *
Reduced libido: *
Sore/dry vagina: *
Body changes: *

Further information about you

Please answer the questions that are relevant to you:

Period changes:
Period changes:
Do you have bleeding after sex?
Do you have bleeding between periods?
Do you smoke?
Have you had a blood clot in your leg or lung?
Have you had a stroker or heart attack before?
Have you used HRT before?
Systolic “Higher” / Diastolic “Lower” / Heart Rate
Do you have a history of breast cancer?
Do you have a history of ovarian cancer?
Do you have a history of liver disease?
Do you have a history of endometriosis?