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Medical Assessment

Are you currently going through menopause?

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Which symptoms of menopause do you suffer from?






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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

When was your last period?





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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Have you ever been prescribed hormone replacement therapy?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

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

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Do you agree to undergo the following checks regularly

  • Blood pressure check and blood test.;
  • Cervical smear.;
  • Breast screening, or mammogram/breast ultrasound.;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you a smoker?

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

What was your most recent blood pressure reading?

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

What is your ethnicity?






Please state your height and weight:

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you allergic to any medicines or other substances?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Does any of the following apply to you?

  • 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;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

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

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Do you agree to the following?

  • 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.;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Do you agree to the following?

  • 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;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Please tick the boxes to confirm the following:

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