DVT Risk Survey

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Consent*

By submitting this form, I consent to my personal and medical information to be sent via email to the email address I provide below.

Patient’s Date of Birth*

MM slash DD slash YYYY

Name*

First Name Last Name

Address*

Street Address Apartment, Suite, Etc. City State Zip Code

Patient Phone Number*

Patient Email*

Patient Doctor Name*

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Date

MM slash DD slash YYYY

Have you tested positive for Covid-19 within the past 24 months?*

Yes

Have you received any Covid-19 vaccinations?*

Yes

Select your age group*

39 and under

40-59

60-74

75 and older

Have you had or currently have a leg, foot, and/or ankle cast or brace?

Yes

Do you have a chronic pulmonary condition?

Yes

Which chronic pulmonary condition do you have?

Do you take oral contraceptives or hormone replacement?

Yes

Which oral contraceptives or hormone replacement do you take?

Have you experienced chronic leg swelling?

Yes

Are you currently a smoker?

Yes

Do you have a history of blood clots?*

Yes

Do you have varicose veins?

Yes

Will you be having surgery within the next month?

Yes

How long will your surgery last?

60 minutes or more

2 hours or more

3 hours or more

Are you having hip or knee replacement surgery?

Yes

Do you have a history of DVT/PE?

Yes

Do you have a family history of DVT/PE?*

Yes

Have you had a previous malignancy or have a current malignancy?

Yes

Have you had a hip, pelvis, ankle, or foot fracture less than 1 month ago?

Yes

Is your mobility currently limited?*

Yes

Will you require bed rest immediately following your procedure?*

Yes

Hidden

DVT Risk Score Total

Need help Filling out Form?

We highly recommend to complete the Risk Survey with the help of a loved one. Make sure you have access to family history so you can record ANY relative who has suffered a blood clot or stroke.

Family members to include, first degree relatives:

Parents
Children
Brothers & Sisters

Family History of Thrombosis, include second degree relatives.

Uncles
Aunts
Nieces
Nephews

Grandparent
Grandchild
Half sibling
Double cousins

ClotIQ Caprini Risk Assessment Video

If you require any assistance completing your DVT Risk Survey, or want help placing your order, please call us.

1-866-995-7778

About ClotIQ

ClotIQ strives to be a driving force for better patient outcomes, a life-saving resource by bringing awareness to the risk of blood clot(s)/DVT and empowering patients to take control of their risk. ClotIQ aims to educate patients by providing information in a simple, intuitive format, while providing an easy process for ordering their Portable Compression Device.

PLEASE NOTE: THIS PRESCRIPTION MEDICAL DEVICE CANNOT BE RETURNED ONCE OPENED.

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info@clotiq.com
1-866-995-7778

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