Direct Oral Anticoagulant – New Patient Questionnaire

Kaweah Health Medical Group

Patient Name: _______________________________ Date of Birth: ________________________

Name of your Anticoagulant medication: ____________________________________________

Dosage strength (how many mg): ___________________________________________________
How many times per day do you take it?:_____________________________________________

Have you ever had any of the following bleeding Yes No

problems:
Red or ruby colored stool
Black stool
Blood in Urine
Spotting or abnormal periods
Nosebleeds
Excessive bruising
Other bleeding

Have you ever had any of the following clotting issues: Yes No
Signs of stroke or TIA (weakness on one side of the body,
garbled speech, drooping face)
Swelling, redness, and pain of one leg
Severe/sudden onset shortness of breath

1. How long have you been taking your anticoagulant medication? ___________________________________________

2. What is the medical reason for taking your anticoagulant medication? ______________________________________

3. In the past 3 months, how many times have you forgotten to take your anticoagulant medication?________________
Do you ever take any extra doses of your anticoagulant medication?________________________________________

4. What is the monthly cost of your anticoagulant medication? ______________________________________________

Is this price affordable for you? _____________________________________________________________________
Do you need any refills sent today? __________________________________________________________________
If yes, which pharmacy? _______________________________________________________________________

5. Have you been hospitalized or had any other major health changes in the past 6 months? If yes, please provide
details: _________________________________________________________________________________________
_______________________________________________________________________________________________

6. In the past 6 months, have you fallen? ________________________________________________________________

If yes, did you sustain any injuries, or hit your head? _____________________________________________________

7. Do you have any surgeries, procedures, or dental work scheduled in the next few months? ______________________
If yes, what kind of surgery: _________________________________________________________________________
Date of Surgery: __________________________________________________________________________________
Surgeon’s name: _________________________________________________________________________________

Please flip this page over

8. If you need to take a medication for pain, what do you usually take? _______________________________________
Do you ever take any Aleve, Advil, Ibuprofen, Naproxen, or Midol? ________________________________________
Do you take Aspirin? ______________________________________________________________________________

9. Did you bring ALL of your medication and supplement/vitamin bottles with you today?_________________________

10. Do you have any questions or concerns regarding your anticoagulant medication you would like to discuss today?
_______________________________________________________________________________________________
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