Coagulation Factor Deficiency Evaluation Questionnaire
Please complete this form to help assess your bleeding history and risk of coagulation factor deficiency.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Do you have a family history of bleeding disorders?
*
Yes
No
Unknown
Have you ever experienced any of the following bleeding symptoms? (Select all that apply)
*
Nosebleeds (epistaxis)
Easy bruising
Prolonged bleeding after cuts
Heavy or prolonged menstrual bleeding
Bleeding after dental procedures
Bleeding into joints or muscles
Other
How often do you experience bleeding symptoms?
*
Please Select
Rarely (less than once a year)
Occasionally (1-3 times a year)
Frequently (more than 3 times a year)
Almost always
Please rate the severity of your bleeding symptoms on a scale from 1 (mild) to 5 (severe).
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Have you ever required medical attention or hospitalization due to bleeding?
*
Yes
No
Are you currently taking any medications that affect bleeding or clotting? (e.g., aspirin, anticoagulants, NSAIDs)
*
Yes
No
If yes, please list the medications:
Have you ever experienced excessive bleeding after surgery, dental work, or childbirth?
*
Yes
No
Not applicable
Is there anything else you would like to share about your bleeding history or symptoms?
Submit Evaluation
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