Wareham Surgery

Streche Road, Wareham, BH20 4PG

Telephone: 01929 553444

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HRT Review

HRT Review

Full Name*
Date of Birth*
DD slash MM slash YYYY
Home Telephone
Mobile Telephone
Do you consent to us contacting you via SMS?
- Yes
- No
Email
Do you consent to us contacting you via email for medical care and advice?
- Yes
- No
Please note all emails may not be secure once they have left Wareham Surgery and if you share an email address we cannot accept responsibility for information being seen by another person.
Do you require a prescription for your HRT?*
- Yes
- No
Name of HRT*
Please take two blood pressure readings at least 5 minutes apart

If you do not have a BP machine please submit the information you can, on the form and your GP will issue you an appropriate prescription.
Date*
DD slash MM slash YYYY
BP Reading (e.g. 120/80)*
Date*
DD slash MM slash YYYY
BP Reading (e.g. 120/80)*
Weight*
Height*
Are you a:*
- Smoker
- Ex Smoker
- I've Never Smoked
How many per day?
When did you stop?
Smoking kills!

If you are interested in support to help you to stop smoking please contact the Smokestop Service: www.livewelldorset.co.uk or call 0800 840 1628

This service can include assessment for drug treatment in the form of nicotine replacement, or alternative medication which may improve your chances of successfully quitting.
General Health Questions
Have you had a Hysterectomy?*
- Yes
- No
Do you have a hormone coil e.g. Mirena?*
- Yes
- No
Have you or a close family member had thrombosis/blood clots?*
- Yes
- No
When was your last period?*
DD slash MM slash YYYY
IF you are on a bleed free HRT have you had any bleeding? (You should not experience bleeding after the first 8 weeks)*
- Yes
- No
- N/A
Do you check your breasts for lumps regularly?*
- Yes
- No
Are you up to date with cervical smears? (3 yearly under the age of 50 and 5 yearly over the age of 50)*
- Yes
- No
Do you feel your symptoms are adequately controlled?*
- Yes
- No
HRT is excellent at relieving vasomotor symptoms such as flushes and sweats and it can improve mood. It also maintains bone density whilst you are taking it, especially if combined with exercise. HRT should be used at the LOWEST DOSE for the SHORTEST PERIOD OF TIME to relieve symptoms as there are risks from HRT such as increased incidences of some cancers, blood clots and stroke.

We suggest you have a GP review at least once a year to reassess HRT risks and benefits.

Please click here to read the HRT information Sheet before you proceed.
Information Sheet*
- I confirm I have downloaded and read the HRT Information Sheet.
Name
This field is for validation purposes and should be left unchanged.

67622

Youth Triage Form age 13-17

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Opening Times

Monday
08:30 to 13:00
14:00 to 18:30
Tuesday
08:30 to 13:00
14:00 to 18:30
Wednesday
08:30 to 13:00
14:00 to 18:30
Thursday
08:30 to 13:00
14:00 to 18:30
Friday
08:30 to 13:00
14:00 to 18:30
Saturday
CLOSED
Sunday
CLOSED

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Patient UK

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Staff Login | Privacy Policy | Accessibility

Patient Participation Group

This is called a virtual PPG because we never have meetings! Members communicate by email. In that way they can keep up to date with news from the Purbeck Network and indeed the NHS as well as share ideas and questions
Name*
First Last
Date of Birth*
Address*
Telephone (home)
Telephone (mobile)
Email
Comments
This field is for validation purposes and should be left unchanged.

55624

Update your Details

Name*
First Last
Date of Birth*
Address*
Phone*
Email*
Preferred method of contact*
- Email
- SMS
- Letter
Smoking Status*
How many per day?*
Phone
This field is for validation purposes and should be left unchanged.

74596

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This website will:

Essential: Remember your cookie permission setting
Essential: Allow session cookies
Essential: Gather information you input into a contact forms, newsletter and other forms across all pages
Essential: Keep track of what you input in a shopping cart
Essential: Authenticate that you are logged into your user account
Essential: Remember language version you selected
Functionality: Remember social media settings
Functionality: Remember selected region and country
Analytics: Keep track of your visited pages and interaction taken
Analytics: Keep track about your location and region based on your IP number
Analytics: Keep track of the time spent on each page
Analytics: Increase the data quality of the statistics functions
Advertising: Use information for tailored advertising with third parties
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