Hematology Biometrics Survey
Please complete this survey to help us better understand hematology-related biometric parameters and experiences. Your responses will remain confidential and are used for research and quality improvement purposes only.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
Email Address
*
example@example.com
Do you have a history of any hematological disorders?
*
Yes
No
Please indicate if you are currently taking any of the following medications (select all that apply):
*
Anticoagulants (e.g., warfarin, heparin)
Antiplatelet agents (e.g., aspirin, clopidogrel)
Iron supplements
Vitamin B12 or folic acid
None
Other
Please enter your most recent hematology biometric values (if known):
Rows
Value
Unit
Hemoglobin
g/dL
10^3/uL
10^6/uL
%
Other
White Blood Cell Count (WBC)
g/dL
10^3/uL
10^6/uL
%
Other
Platelet Count
g/dL
10^3/uL
10^6/uL
%
Other
Hematocrit
g/dL
10^3/uL
10^6/uL
%
Other
Mean Corpuscular Volume (MCV)
g/dL
10^3/uL
10^6/uL
%
Other
In the past month, how often have you experienced the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Fatigue
1
2
3
4
5
Bruising
6
7
8
9
10
Bleeding (nose/gums)
11
12
13
14
15
Shortness of breath
16
17
18
19
20
Dizziness
21
22
23
24
25
On a scale of 1 to 5, how would you rate your overall well-being in the last week?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Please rate your satisfaction with your current hematology care provider.
1
2
3
4
5
Do you use any of the following lifestyle factors? (Select all that apply)
Tobacco products
Alcohol
Recreational drugs
None of the above
Other
Do you have any additional comments or information related to your hematology health?
Submit Survey
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