HRT pre-counselling questionnaire

Use this form to provide information about your symptoms and medical history, which helps us assess if HRT is right for you.

You can use this service if you:

• are registered at the surgery

Before you start

We’ll ask you for:

• your first and last name, date of birth, sex, postcode, email and phone number
• if applicable, the details of the person you are completing the form on behalf of

Start now

You can also phone us on The Vernon Street Medical Centre 01332 332812 or The Lanes Medical Centre 01332 332812.