Medical Assessment

Are you currently going through menopause?

Yes No

Can you let us know why do you require hormone replacement therapy?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Which symptoms of menopause do you suffer from?

hot flushes
mood swings
night sweats
vaginal dryness
other: please specify

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

When was your last period?

0-6 months ago
6-12 months ago
1-3 years ago
over 3 years ago

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you ever been prescribed hormone replacement therapy?

Yes No

Please provide the name, dosage and when were you lastly prescribed that medication.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you had your womb (uterus) removed, also known as hysterectomy?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you using any additional progesterone such as Utrogestan, Provera, Norethisterone or do you have a Mirena coil in place.

Yes No

Please provide more information. If you have a Mirena coil, when was this fitted?

If you have not undergone a womb removal (hysterectomy), progesterone is necessary to protect the endometrial lining and prevent hyperplasia. Would you like us to contact you to discuss further?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to undergo the following checks regularly

Yes No

Blood pressure check and blood test.;
Cervical smear.;
Breast screening, or mammogram/breast ultrasound.;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you a smoker?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

What was your most recent blood pressure reading?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

What is your ethnicity?

Asian
Black, Caribbean, or African
Mixed or multiple ethnic groups
White
Other

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Please state your height and weight:

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you allergic to any medicines or other substances?

Yes No

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Does any of the following apply to you?

Yes No

you have or have ever had breast cancer, or if you are suspected of having it ;
you have cancer which is sensitive to oestrogens (e.g. cancer of the womb lining - endometrium) or if you are suspected of having it ;
you have any unexplained vaginal bleeding ;
you have excessive thickening of the womb lining (endometrial hyperplasia) that is not being treated. ;
you have or have ever had a blood clot in a vein (thrombosis), such as in the legs (deep venous thrombosis) or the lungs (pulmonary embolism);
you have a blood clotting disorder (such as protein C, protein S, or antithrombin deficiency);
you have or recently have had a disease caused by blood clots in the arteries, such as a heart attack, stroke or angina;
you have or have ever had a liver disease and your liver function tests have not returned to normal;
you have a rare blood problem called “porphyria” which is passed down in families (inherited);
You suffer from any other condition that we should know about;

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any medication (prescription or over the counter)

Yes No

Please provide the name, dosage and the reason why you are taking that medication or medications

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

Combined HRT creates an increased risk of breast cancer.;
HRT creates an increased risk of womb cancer.;
HRT tablets create an increased risk of blood clots.;
HRT creates an increased risk of cardiovascular disease (if started at age 60 or over).;
Manufacturers advise that HRT products should not be used for more than 5 years due to lack of data on their risks after this point.;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

you have answered truthfully to all the questions, and you are aware that any incorrect information you provided can present a potential danger to your health;
you will inform your doctor about any unusual side effects;
you will read the patient information leaflet supplied with your medication;
you will not exceed the maximum daily dose of this medication;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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