What does this Questionnaire do?
The Accurx HRT Review questionnaire allows the sending of an online questionnaire to patients to collect information in regard their hormone replacement therapy in order to facilitate the review of their treatment regimen.
The questionnaire link is sent via SMS or email. The patient fills in the questionnaire through a browser, so they can use their phone, tablet, laptop or desktop to complete it.
The responses are returned to the organisation and can be saved directly into the clinical record (EMIS or SystmOne) as a coded entry. The responses can have additional notes added, be assigned to other colleagues and be marked as urgent.
Questions
1. Do you know the name of the hormone replacement therapy (HRT) that you want?
Yes
No
No, but I'd like the same one I was given last time
If 'Yes'
2. What's the name of your HRT?
Enter text
3. Have you started taking any new regular medications or health supplements recently?
This includes medications prescribed privately (e.g. weight loss treatments) and over the counter medications or supplements (e.g. St John’s Wort)
Yes
No
if 'Yes'
4. What are the names of the medications or health supplements that you have started taking since your last prescription?
It’s important to know about other medication or supplements you are taking in case they interact or interfere with your current medication.
Enter text
5. Have you been diagnosed with any new health conditions since we last issued your HRT?
These could be any conditions but in particular: any breast or ovarian conditions, blood clots or a clotting disorder, cancer, heart disease, liver disease, migraines or diabetes
Yes
No
if 'Yes'
6. What new health conditions have you been diagnosed with since your last HRT issue?
Enter text
7. Is HRT helping your symptoms?
Yes
No
8. How long have you been taking HRT?
Enter text
9. Are you having any side effects or problems from your HRT?
Yes
No
If 'Yes'
10. Please describe any side effects or problems here
Enter text
11. Do you have any vaginal dryness or discomfort?
Yes
No
12. Are you up to date with your breast screening (mammogram)?
A mammogram is a type of X-ray that looks for breast cancer. In the UK, you should be invited to have a mammogram every 3 years between the ages of 50 and 70 unless you have been told otherwise by a healthcare professional.
Yes
No
I'm not sure
13. Are you up to date with your cervical screening (smear test)?
Unless you have been told otherwise by a healthcare professional, you should be invited to have a smear test every 3 years (3-5 years for practices in England) between the ages of 25 and 49, every 5 years from age 50 to 64 and then over 65 if one of your last 3 smear tests was abnormal.
Yes
No
I'm not sure
14. Do you have a family history of breast cancer?
Yes
No
15. Have you had any new or unexpected vaginal bleeding/spotting?
Such as after sex, between periods or after 12 months of not having a period
Yes
No
16. Have you had a hysterectomy?
A hysterectomy is where you’ve had surgery to remove your womb (uterus).
Yes
No
If 'No'
17. Are you currently using contraception?
Please note, other than the Mirena Coil, HRT does not act as contraception.
Yes
No
If 'Yes'
18. Which method of contraception do you use?
Enter Text
19. Do you require advice about contraception?
Yes
No
20. What is your smoking status?
Current Smoker
Ex-smoker
Never Smoked
If 'Current smoker' or 'Ex-smoker'
21. How much do you smoke? or How much did you smoke?
<1 cigarette or equivalent per day
1-9 cigarettes or equivalent per day
10-19 cigarettes or equivalent per day
20-39 cigarettes or equivalent per day
40+ cigarettes or equivalent per day
22. How many years did you smoke for?
Enter text
23. Are you able to provide a blood pressure reading?
As part of the review of your HRT we need an up-to-date blood pressure reading
Yes
No
If 'Yes'
26. Do you know your weight?
Yes
No
If 'Yes'
27. Please enter your weight in kilograms.
If you only know your weight in stone and pounds, please use the converter here
Enter the number in kg
28. Do you know your height?
Yes
No
29. Please enter your height in metres.
For example, 1.67 metres.
Maximum allowed height is 3.00 metres.
If you only know your height in feet and inches, please use this converter here.
Yes
No
30. Are you considering stopping your HRT?
Yes
No
31. Is there anything else regarding your HRT that you would like to change or discuss?
Enter text
When they have submitted their answers, they will be thanked for completing the survey👇
SNOMED codes added on response
The codes added are in bold and italics
If able to complete BP at home:
Blood pressure recorded by the patient at home 413153004
Self-reported systolic blood pressure (Concept ID: 1162737008 / CTV3 2469)
Self-reported diastolic blood pressure (Concept ID: 1162735000 / CTV3 246A)
If able to complete weight and height:
Body weight (observable entity) - 27113001
Standing height (observable entity) - 248333004
Body mass index (observable entity) - 60621009
If selected "current smoker":
Smoker (finding) - 77176002
Trivial cigarette smoker (less than one cigarette/day) (finding) - 266920004
Light cigarette smoker (1-9 cigs/day) (finding) - 160603005
Moderate cigarette smoker (10-19 cigs/day) (finding) - 160604004
Heavy cigarette smoker (20-39 cigs/day) (finding) - 160605003
Very heavy cigarette smoker (40+ cigs/day) (finding) - 160606002
If selected "ex-smoker":
Ex-smoker (finding) - 8517006
Ex-trivial cigarette smoker (<1/day) (finding) - 266921000
Ex-light cigarette smoker (1-9/day) (finding) - 266922007
Ex-moderate cigarette smoker (10-19/day) (finding) - 266923002
Ex-heavy cigarette smoker (20-39/day) (finding) - 266924008
Ex-very heavy cigarette smoker (40+/day) (finding) - 266925009
If selected "never smoked":
Never smoked - 266919005
Additional SNOMED codes:
Finding of tobacco smoking behaviour - 365981007
If selected "current smoker":
Smoking cessation advice - 225323000
Current smoker annual review - 505651000000103
If selected "ex-smoker":
Ex-smoker annual review - 505761000000105
If selected "never smoked":
Non-smoker annual review - 505681000000109
F.A.Q's
Why do you not include the 'Hormone replacement therapy review' SNOMED code?
We don't add this code as the HRT review isn't completed through the questionnaire alone. A review of the information by a clinician is required, who will then make a decision on the correct course of action.
If you still have any questions or concerns, feel free to chat with us using the green message bubble in the bottom right-hand corner of this page. 👉