Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Please provide more detail.
Are you currently:
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Do you currently have or have you had any medical problems or surgeries/operations, for example:
Please provide more details
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you have any allergies to medications or any other substances?
Please list everything you are allergic to and what symptoms you experience.
Do you take or use any recreational drugs?
Please list everything you use. This information will not be shared with anyone apart from our prescribers.
What is your blood pressure?
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Are you currently prescribed HRT by your GP or specialist?
Please provide more information.
(Please note that we will not initiate anyone on HRT. This service is for continuation of your treatment)
Have you ever been diagnosed with any mental health conditions?
Please provide more information as well as the treatment you are on.
Do any of the following apply to you:
Please list any of the above which apply to you
Please enter your height and weight
What is your height (cm)?
What is your height (feet)?
What is your weight (kg)?
What is your weight (stone/pounds)?
BMI
When was your last menstrual period?
When did you last have a cervical smear?
It is important to keep up to date with your cervical smears. This will allow us to make an appropriate clinical decision when prescribing continuation of your menopause treatment. If you would like more information about cervical screening, please click here.
Have you had a mammogram within the last 5 years?
Please provide the date of your last mammogram (DD/MM/YYYY)
It is advisable that all women aged 50-70 have a breast mammogram every 3 years.
Have you had a hysterectomy (womb removed)?
Please provide details of when and why it was removed.
Please also include if you have you had your ovaries removed.
Are you currently taking any female hormones such as hormone replacement therapy (HRT)?
Which HRT are you taking?
How many consecutive years have you been taking HRT for?
Who originally prescribed this HRT for you?
Please provide more information
Are you currently using an IUD (intra-uterine device, coil)?
Which IUD are you using and when (DD/MM/YYYY) did you have it fitted or changed?
Have you noticed any unexpected vaginal bleeding in the last 12 months?
Do you have a personal or family history of breast or endometrial (womb) cancer?
Do you have any of the following symptoms:
What symptoms are you experiencing?
Please confirm that you understand the following:
Are you aware that you should stop taking HRT and see your doctor if you experience any of the following:
I am aware that:
To help support your order, if you are currently using HRT, please upload a picture of your current treatment here:
This can include:
This is to ensure that this treatment is safe and effective for you. Please note that failure to upload may result in delays with your order until we have received this information.
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
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