Appendix A

Annual checklist for hormone replacement therapy:
(Please give a "tick" ______ or circle the appropriate answer in the space provided)
 
If HRT is prescribed,
 
1. Uterus status is checked
___________
     
2. Indication for HRT is checked
___________
  (Please circle the indication as follows: (i) Vasomotor symptom (ii) Osteoporosis (iii) others)    
       
3. Absolute contraindications (existing breast/endometrial cancer, acute liver disease, venous thrombosis) are assessed at least once  
___________
       
4. Advice on 3-yearly mammography screening is given  
___________
 

(If done, please state where and when ____________________________________)
(Please circle the result as follows: (i) Normal (ii) Abnormal)

   
       
5. Risks and benefits of HRT are counselled  
___________
       
       
       
 
Date Completed: ___________________________   Signature: ___________________________