{"id":1118,"date":"2026-08-22T10:52:22","date_gmt":"2026-08-22T09:52:22","guid":{"rendered":"https:\/\/surgeryweb-scot.org.uk\/n31916\/?page_id=1118"},"modified":"2026-08-22T10:52:22","modified_gmt":"2026-08-22T09:52:22","slug":"hrt-review-form","status":"publish","type":"page","link":"https:\/\/surgeryweb-scot.org.uk\/n31916\/hrt-review-form\/","title":{"rendered":"HRT Review Form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_25' style='display:none'><div id='gf_25' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_25' id='gform_25'  action='\/n31916\/wp-json\/wp\/v2\/pages\/1118#gf_25' data-formid='25' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_25' class='gform_fields top_label form_sublabel_above description_above validation_above'><div id=\"field_25_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_1'><span class='gform-field-label__text'>Full Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_25_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_25_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_25_3' class='ginput_container ginput_complex gform-grid-row'>\n                                    <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_25_3_2_container'>\n                                        <label for='input_25_3_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <input type='number' maxlength='2' name='input_3[]' id='input_25_3_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                    <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_25_3_1_container'>\n                                    <label for='input_25_3_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <input type='number' maxlength='2' name='input_3[]' id='input_25_3_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                               <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_25_3_3_container'>\n                                        <label for='input_25_3_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                        <input type='number' maxlength='4' name='input_3[]' id='input_25_3_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                   <\/div>\n                                <\/div><\/fieldset><fieldset id=\"field_25_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-formatted gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_phone'>\n\t\t\t<div class=\"gform-phone\" role=\"application\">\n\t\t\t\t<div class=\"gform-phone__input-wrapper\">\n\t\t\t\t\t<span class=\"ginput_country-selector_container\">\n\t\t\t\t\t\t<label for='country_selector_button_4' id='country_selector_button_4_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n\t\t\t\t\t\t<button type=\"button\" id=\"country_selector_button_4\" class=\"gform-phone__country-selector gform-theme-button gform-theme-button--tertiary\" aria-haspopup=\"listbox\" aria-expanded=\"false\" aria-controls=\"gform_phone_dropdown_6a8a0398c2899\" aria-label=\"Select country\" >\n\t\t\t\t\t\t\t<span class=\"gform-phone__flag-icon gform-phone__flag-icon--gb\"><\/span>\n\t\t\t\t\t\t\t<span class=\"gform-phone__dial-code\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<span class=\"ginput_phone_container\">\n\t\t\t\t\t\t<label for='input_25_4_visible' id='input_25_4_visible_label' class='gform-field-label gform-field-label--type-sub '>Phone Number<\/label>\n\t\t\t\t\t\t<input type=\"tel\" class=\"gform-phone__input\" id=\"input_25_4_visible\" name=\"\" autocomplete=\"tel\" value=\"\"   aria-required=\"true\" aria-invalid=\"false\"  >\n\t\t\t\t\t\t\n\t\t\t\t\t<\/span>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"gform-phone__dropdown gform-phone__dropdown--hidden\" role=\"listbox\" id=\"gform_phone_dropdown_6a8a0398c2899\" tabindex=\"-1\">\n\t\t\t\t\t<div class=\"gform-phone__search-wrapper\">\n\t\t\t\t\t\t<input type=\"text\" class=\"gform-phone__search\" placeholder=\"Search countries\" aria-label=\"Search for a country\" aria-controls=\"gform_phone_dropdown_6a8a0398c2899_list\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<ul class=\"gform-phone__country-list gform-ul-reset\" id=\"gform_phone_dropdown_6a8a0398c2899_list\" role=\"listbox\" aria-label=\"Country list\">\n\t\t\t\t\t\t<!-- Country items will be populated by JavaScript -->\n\t\t\t\t\t<\/ul>\n\t\t\t\t\t<div class=\"gform-phone__aria-live-search-status\" aria-live=\"polite\" aria-atomic=\"true\" style=\"position: absolute; width: 1px; height: 1px; margin: -1px; border: 0; padding: 0; overflow: hidden; clip: rect(0, 0, 0, 0); clip-path: inset(50%); white-space: nowrap;\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"gform-phone__aria-live\" aria-live=\"polite\" aria-atomic=\"true\" style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0 0 0 0); clip-path: inset(50%); border: 0; white-space: nowrap;\"><\/div>\n\t\t\t<\/div><input name='input_4' id='input_25_4' type='hidden' value='' class='large' data-phone-format='formatted' data-default-country='gb' data-show-country-code='false' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/fieldset><div id=\"field_25_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_5'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_25_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_25_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have a hormonal coil in place? (e.g. Mirena, Jaydess, Kyleena or Levosert)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_30'>\n\t\t\t<div class='gchoice gchoice_25_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_25_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_30_0' id='label_25_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_25_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_30_1' id='label_25_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_25_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_33'><span class='gform-field-label__text'>Please specify the name of coil and when you had it fitted<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_25_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_25_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you had surgery to remove your womb (hysterectomy)?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_34'>\n\t\t\t<div class='gchoice gchoice_25_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_25_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_34_0' id='label_25_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_25_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_34_1' id='label_25_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_25_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you also had your ovaries removed?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_35'>\n\t\t\t<div class='gchoice gchoice_25_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_25_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_35_0' id='label_25_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_25_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_35_1' id='label_25_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_25_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you up to date with your cervical screening (smear tests) if applicable?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_36'>\n\t\t\t<div class='gchoice gchoice_25_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_25_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_36_0' id='label_25_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_25_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_36_1' id='label_25_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Not applicable'  id='choice_25_36_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_36_2' id='label_25_36_2' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_25_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you up to date with your breast screening (mammograms) if applicable?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_37'>\n\t\t\t<div class='gchoice gchoice_25_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_25_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_37_0' id='label_25_37_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_25_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_37_1' id='label_25_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_37_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Not applicable'  id='choice_25_37_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_37_2' id='label_25_37_2' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_25_32\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><p>To continue safely prescribing HRT, we need to ensure that you remain aware of the potential risks with HRT. Please click the links below to information from NHS Inform and the British Menopause Society on the risks and benefits of HRT.<\/p> \n<p><a href=\"https:\/\/www.nhsinform.scot\/tests-and-treatments\/medicines-and-medical-aids\/types-of-medicine\/hormone-replacement-therapy-hrt\/\" target=\"_blank\">Hormone replacement therapy (HRT) | NHS inform<\/a><\/p>\n<p><a href=\"https:\/\/www.womens-health-concern.org\/help-and-advice\/factsheets\/\" target=\"_blank\">WHC factsheets and other helpful resources - Women's Health Concern<\/a><\/p><\/div><fieldset id=\"field_25_31\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Declaration<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_31.1' id='input_25_31_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_25_31_1' ><span class='gform-field-label__text'>I confirm that I am aware of and understand the potential risks of HRT<\/span><\/label><input type='hidden' name='input_31.2' value='I confirm that I am aware of and understand the potential risks of HRT' class='gform_hidden' \/><input type='hidden' name='input_31.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_25_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_38'><span class='gform-field-label__text'>Name(s) and dose(s) of HRT currently taking<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_25_38' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_25_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_39'><span class='gform-field-label__text'>How long have you been taking your current HRT for?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_25_39' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_25_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Does your HRT help manage your menopausal symptoms?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_40'>\n\t\t\t<div class='gchoice gchoice_25_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_25_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_40_0' id='label_25_40_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_25_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_40_1' id='label_25_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_25_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_41'><span class='gform-field-label__text'>Please provide details below<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_25_41' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_25_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have any problems with your current HRT?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_42'>\n\t\t\t<div class='gchoice gchoice_25_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_25_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_42_0' id='label_25_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_25_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_42_1' id='label_25_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_25_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_43'><span class='gform-field-label__text'>Please provide more information about the problems you are having<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_25_43' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_25_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have periods or bleeding with your HRT?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_9'>\n\t\t\t<div class='gchoice gchoice_25_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_25_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_9_0' id='label_25_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_25_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_9_1' id='label_25_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_25_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Has your bleeding pattern changed since your last review or are you having any irregular bleeding e.g. between periods or after intercourse?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_10'>\n\t\t\t<div class='gchoice gchoice_25_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Yes'  id='choice_25_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_10_0' id='label_25_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='No'  id='choice_25_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_10_1' id='label_25_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_25_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have any new breast symptoms that weren&#039;t there before?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_11'>\n\t\t\t<div class='gchoice gchoice_25_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_25_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_11_0' id='label_25_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_25_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_11_1' id='label_25_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_25_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you ever miss or forget to take your HRT?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_44'>\n\t\t\t<div class='gchoice gchoice_25_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_25_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_44_0' id='label_25_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_25_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_44_1' id='label_25_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_25_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you require contraception? HRT is not a contraceptive method.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_45'>\n\t\t\t<div class='gchoice gchoice_25_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Yes'  id='choice_25_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_45_0' id='label_25_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_25_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_45_1' id='label_25_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_25_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you currently receiving weight reducing injections from a private clinic (e.g. Mounjaro, Wegovy)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_15'>\n\t\t\t<div class='gchoice gchoice_25_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_25_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_15_0' id='label_25_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_25_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_15_1' id='label_25_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_25_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_16'><span class='gform-field-label__text'>Please provide the details of the injection you are taking - name, dose and date commenced - as this could affect your contraception.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_25_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_25_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Have you been diagnosed with or experienced any of the following conditions:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_25_17'><div class='gchoice gchoice_25_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Migraines (with or without aura) and\/or new headaches'  id='choice_25_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_1' id='label_25_17_1' class='gform-field-label gform-field-label--type-inline'>Migraines (with or without aura) and\/or new headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Deep vein thrombosis (a blood clot in the veins of the leg)'  id='choice_25_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_2' id='label_25_17_2' class='gform-field-label gform-field-label--type-inline'>Deep vein thrombosis (a blood clot in the veins of the leg)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Pulmonary embolism (a blood clot in the lungs)'  id='choice_25_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_3' id='label_25_17_3' class='gform-field-label gform-field-label--type-inline'>Pulmonary embolism (a blood clot in the lungs)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Breast Cancer'  id='choice_25_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_4' id='label_25_17_4' class='gform-field-label gform-field-label--type-inline'>Breast Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Stroke\/TIA\/heart attack'  id='choice_25_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_5' id='label_25_17_5' class='gform-field-label gform-field-label--type-inline'>Stroke\/TIA\/heart attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_17_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.6' type='checkbox'  value='Gynaecological cancers'  id='choice_25_17_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_6' id='label_25_17_6' class='gform-field-label gform-field-label--type-inline'>Gynaecological cancers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_17_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.7' type='checkbox'  value='High blood pressure'  id='choice_25_17_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_7' id='label_25_17_7' class='gform-field-label gform-field-label--type-inline'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_17_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.8' type='checkbox'  value='Diabetes'  id='choice_25_17_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_8' id='label_25_17_8' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_17_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.9' type='checkbox'  value='Epilepsy'  id='choice_25_17_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_9' id='label_25_17_9' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_17_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.11' type='checkbox'  value='Gallbladder or liver disease'  id='choice_25_17_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_11' id='label_25_17_11' class='gform-field-label gform-field-label--type-inline'>Gallbladder or liver disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_17_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.12' type='checkbox'  value='None of the above'  id='choice_25_17_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_17_12' id='label_25_17_12' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_25_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Have any of your immediate family (parents or siblings) been diagnosed with any of the following conditions<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_25_18'><div class='gchoice gchoice_25_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Deep vein thrombosis (a blood clot in the veins of the leg)'  id='choice_25_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_18_1' id='label_25_18_1' class='gform-field-label gform-field-label--type-inline'>Deep vein thrombosis (a blood clot in the veins of the leg)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Pulmonary embolism (a blood clot in the lungs)'  id='choice_25_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_18_2' id='label_25_18_2' class='gform-field-label gform-field-label--type-inline'>Pulmonary embolism (a blood clot in the lungs)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Gynaecological cancers'  id='choice_25_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_18_3' id='label_25_18_3' class='gform-field-label gform-field-label--type-inline'>Gynaecological cancers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Stroke\/TIA\/heart attack'  id='choice_25_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_18_4' id='label_25_18_4' class='gform-field-label gform-field-label--type-inline'>Stroke\/TIA\/heart attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='Breast Cancer'  id='choice_25_18_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_18_5' id='label_25_18_5' class='gform-field-label gform-field-label--type-inline'>Breast Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_25_18_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.6' type='checkbox'  value='None of the above'  id='choice_25_18_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_25_18_6' id='label_25_18_6' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_25_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_20'><span class='gform-field-label__text'>Weight (kg)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_25_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_25_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_21'><span class='gform-field-label__text'>Height (cm)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_25_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_25_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_22'><span class='gform-field-label__text'>Blood pressure (mmHg) from a home monitor or via a local pharmacy that offers BP check<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_25_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_25_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Smoking Status<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_24'>\n\t\t\t<div class='gchoice gchoice_25_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Never smoked'  id='choice_25_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_24_0' id='label_25_24_0' class='gform-field-label gform-field-label--type-inline'>Never smoked<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Ex-smoker'  id='choice_25_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_24_1' id='label_25_24_1' class='gform-field-label gform-field-label--type-inline'>Ex-smoker<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Current smoker'  id='choice_25_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_24_2' id='label_25_24_2' class='gform-field-label gform-field-label--type-inline'>Current smoker<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_25_25\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date Stopped<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_25_25' class='ginput_container ginput_complex gform-grid-row'>\n                                    <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_25_25_2_container'>\n                                        <label for='input_25_25_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <input type='number' maxlength='2' name='input_25[]' id='input_25_25_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                    <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_25_25_1_container'>\n                                    <label for='input_25_25_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <input type='number' maxlength='2' name='input_25[]' id='input_25_25_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                               <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_25_25_3_container'>\n                                        <label for='input_25_25_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                        <input type='number' maxlength='4' name='input_25[]' id='input_25_25_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                   <\/div>\n                                <\/div><\/fieldset><div id=\"field_25_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_26'><span class='gform-field-label__text'>Please advise how many cigarettes per day you smoke<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_25_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_25_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Alcohol intake - do you drink alcohol?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_25_27'>\n\t\t\t<div class='gchoice gchoice_25_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Yes'  id='choice_25_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_27_0' id='label_25_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_25_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_25_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_25_27_1' id='label_25_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_25_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_25_28'><span class='gform-field-label__text'>How many units per week on average do you drink? 1 unit = half a pint of beer, a small glass of wine or one 25ml measure of spirit.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_25_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_25_29\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3>WHAT HAPPENS NEXT?<\/h3>\n<p>Once returned to the practice, a clinician will review your answers and issue your prescription as appropriate. <\/p>\n<p>If there are any queries or we have reason to speak with you before your prescription can be issued, you will be contacted to arrange an appointment. <\/p>\n<p>If there are no queries and we do not need to speak with you, your prescription will be issued for a year's supply* and sent to your preferred pharmacy. Please allow 7 working days before collection. <\/p>\n<p>We will ask you to complete this review yearly, prior to your prescription being reauthorised, to ensure that it remains appropriate for you to continue taking.<\/p><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_25' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> <input type='hidden' name='gform_ajax' value='form_id=25&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=a56a77461442450b1883510e7382b946' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_25' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_25' id='gform_theme_25' value='gravity-theme' \/>\n            <input type='hidden' 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