ICH Risk Assessment Form
Complete this form to assess a patient's risk factors for Intracerebral Hemorrhage (ICH).
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Sex
*
Male
Female
Other
Medical History: Please indicate if the patient has any of the following conditions.
Hypertension
Diabetes Mellitus
Previous Stroke or TIA
Atrial Fibrillation
Anticoagulant Use
Antiplatelet Use
Smoking
Alcohol Use
Other
Blood Pressure (mmHg)
*
Presenting Symptoms (select all that apply)
*
Sudden severe headache
Loss of consciousness
Nausea or vomiting
Weakness or numbness
Speech difficulties
Seizures
Other
Risk Factor Assessment Table
*
Rows
Present
Absent
Unknown
Hypertension
1
2
3
Anticoagulant Use
4
5
6
Previous Stroke
7
8
9
Heavy Alcohol Use
10
11
12
Family History of ICH
13
14
15
How would you rate the patient's overall risk for ICH based on your assessment?
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Additional Notes (optional)
Signature of Assessor
*
Submit Assessment
Submit Assessment
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