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DEEP VEIN THROMBOSIS RISK ASSESSMENT
Medical professionals at the Idaho Eye Center are required to assess our surgical patients for their risk of developing a deep vein thrombosis (DVT) prior to their surgery. Although the development of a DVT related to an ophthalmic surgery is low, we assess each of our patients to take preventative measures for optimal patient outcome. Please complete the following questionnaire
Name
*
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Have you had surgery (more than 45 minutes) within the last month?
*
Yes
No
Do you have varicose veins?
*
Yes
No
Do you have a history of Inflammatory Bowel Disease (IBD, Crohn’s, ulcerative colitis)?
*
Yes
No
Do you currently have swollen legs?
*
Yes
No
Have you had a heart attack within the last month?
*
Yes
No
Have you had congestive heart failure within the last month?
*
Yes
No
Have you been on bed rest or have had restricted mobility during the last month? If yes, how long?
*
Yes
No
How long?
Have you had a non-removable cast or brace on your leg that has restricted movement within the last month?
*
Yes
No
Do you have a history of or currently have cancer? (excluding basal cell skin cancer)
*
Yes
No
Have you had a central venous access, PICC line or port within the last month?
*
Yes
No
Do you have a history of or currently have Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)?
*
Yes
No
Do you have a family history of Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)?
*
Yes
No
Do you have a personal or family history of a positive blood test indicating an increased risk of blood clotting?
*
Yes
No
Do you currently have a fractured leg, hip, or pelvis?
*
Yes
No
Have you recently had multiple traumatic injuries (example: multiple broken bones due to a fall or car accident)?
*
Yes
No
Have you had a spinal cord injury resulting in paralysis?
*
Yes
No
Signature
DateTime
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