Prescriptions: HRT + Asthma + Medication Review

We review any regular medication on a repeat prescription annually and wherever possible the doctor will do this without you having to attend the surgery.

If you have been advised by the surgery that your medication review is due please use this form. Ensure that you complete any outstanding blood test requests prior to filling out this form. You will know if you need to have a blood test by reading the prescription note or text message you were sent by us.

Certain medications need regularly monitoring (often yearly). This may include 

  • Blood tests
  • Blood pressure checks

You will be contacted by our team if this is required.

Hormone replacement therapy (HRT) is a treatment to relieve symptoms of the menopause. It replaces hormones that are at a lower level as you approach the menopause.

The main benefit of HRT is that it can help relieve most of the menopausal symptoms, including: hot flushes, night sweats, mood swings, vaginal dryness and reduced sex drive.

Many of these symptoms pass after a few years, but they can be unpleasant and taking HRT can offer relief for many women.

Whilst the benefits of HRT often outweigh the risks, some types of HRT can increase your risk of breast cancer and blood clots. It is important to remain vigilant for signs of breast cancer & we encourage you to attend breast screening when invited

To ensure your medication is prescribed safely and you are aware of all this information we review your prescription every 12 months. 

If your review is now due please complete the following form and fill in as much information as possible. Some of this information will already be included in your medical records but this is a good opportunity to update any changes.

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are significantly deteriorating or you are having any concerns please make a telephone appointment with our Nurse.


You may have received a text or a letter. This is because asthma reviews are an essential way of monitoring your symptoms and ensuring your medication is safe and appropriate. 

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 2 working days to complete. Please DO NOT call before 2 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Home ButtonOnline Consultation Information




Prescriptions: HRT + Asthma + Medication Review
An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention.
Please note that your answer will not be seen immediately and you should direct any URGENT queries to reception.
HRT Review
A total hysterectomy is where your uterus and cervix have been removed
If you are no longer having periods or you have a Mirena coil please indicate this here
This might include unusual bleeding in between regular periods, bleeding after sex or bleeding more than 12 months after your last period
Out of 1,000 women taking HRT between the ages of 50-59, there will be an extra 4 cases of breast cancer diagnosed every 5 years. If you use oestrogen only HRT there are 4 fewer cases diagnosed.
A recent study found that for every 1,000 women taking HRT for 5 years, there will be 1 extra case of ovarian cancer
It is thought that the risk of developing a blood clot is 2 to 4 times higher than normal for women taking HRT tablets. But as the risk of menopausal women developing blood clots is usually very low, the overall risk from taking H
The evidence shows that HRT does not significantly increase the risk of cardiovascular disease (including heart disease and strokes) when started before 60 years of age. Oestrogen-only HRT is associated with no, or reduced, risk of heart disease. Combined HRT is associated with little or no increase in the risk of heart disease. Taking oestrogen tablets is associated with a small increase in the risk of stroke, but the risk of stroke for women under age 60 is generally very low, so the overall risk is still small
Whilst a Mirena coil offers contraception other methods of HRT do not.
If you would like to change to a different regime we will call you to discuss this further
Medication Review
Please state the drug in question and the side effect. E.g. Paracetamol: Constipation
It is really important to try and get a home reading as this will help speed up the process. If no reading is given you will need to attend the practice to have your blood pressure taken.
If you are struggling with your mental health please contact the practice or if out of hours or in an emergency call the CRISIS team: 0300 200 0011 and select option 1.
Please note that if your mental health is currently significantly impact and you are concerned for your well-being you must contact the crisis team on 0300 200 0011 and select option 1 or 999.
If no write: NO. If yes, please state the name and dose of these medications.
If you are a current smoker, out of 1,000 women aged 50-59 there will be an additional 3 cases of breast cancer diagnosed every 5 years.
If you drink more than 2 units of alcohol each day, out of 1,000 women aged 50-59 there will be an additional 5 cases of breast cancer diagnosed every 5 years.
If you are overweight or obese (your BMI is equal or greater than 30) out of 1,000 women aged 50-59 there will be an additional 24 cases of breast cancer diagnosed every 5 years.
If you do at least 2.5 hours of moderate exercise each week, out of 1,000 women aged 50-59 there will be 7 FEWER cases of breast cancer diagnosed every 5 years.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

Information submitted through all secure forms, with the exception of the Leamington Primary Care Network Coil insertion/replacement form and Implant insertion/replacement/removal form, is secured with a private key and is accessed over a secure connection by nominated staff. Information submitted through the Leamington Primary Care Network Coil insertion/replacement form and Implant insertion/replacement/removal form is sent to The Leamington Primary Care Network via secure email.

We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 365 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.