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Follow-up Questionnaire (In Hospital Version)

PATIENT DETAILS


Hospital Number:
or Hospital Name: ______________________________________
Patient Details:

Family Name: ______<<family name>>__________________________
Given Name/s: ______<<given name>>__________________________
Date of Birth: _________/________/_______ (dd/mm/yyyy)
Sex: Male

ABOUT THE STROKE:

Was stroke diagnosis confirmed in this patient?
If not a stroke, please specify the diagnosis:_________________________________ Was the stroke due to: cerebral infarction?

DRUGS DURING HOSPITAL STAY
Has this patient taken any of the following drugs since randomisation (Tick all appropriate)?
If patient given Heparin or Warfarin during admission give reason(s):
Atrial Fibrillation

STOCKING USE
Since randomisation, has this patient:
Did this patient wear stockings prior to randomisation? Yes


Worn full length stockings at any time?
If yes on which leg(s)? Right
Worn below knee stockings at any time? Yes
If yes on which leg(s)? Right
If the allocated stocking use has not been followed, please give reasons below ____________________________________________________________________________ If wore stockings at any time since randomisation
Date stockings first worn
Number of days (between these dates) stockings not worn ______
If compression stockings were not worn each day till now, please tick the main reason below: Please specify other difficulties ___________________________________________________
MAJOR EVENTS DURING HOSPITAL STAY

Since randomisation has this patient had a:
Symptomatic or clinically apparent DVT?

(not clinically silent DVT diagnosed on screening Doppler) If yes give date 1st diagnosed _ / _ /___

Pulmonary Embolism?
If yes give date 1st diagnosed _ / _ /___


Skin break on either leg?

If yes give date 1st diagnosed _ / _ /___

Evidence of post-DVT leg syndrome?

If yes give date 1st diagnosed _ / _ /___

None of these


DETAILS OF ANY SYMPTOMATIC DVT

If Symptomatic DVT diagnosed how was it confirmed?
Doppler ultrasound
Please specify the location(s) of any symptomatic DVT(s) Right leg

DETAILS OF ANY PULMONARY EMBOLISM
If Pulmonary embolism diagnosed how was this confirmed?
DETAILS OF ANY POST DVT SYNDROME

If Post DVT syndrome diagnosed
Was there ankle swelling?
Right leg
Was there ulceration?

CURRENT TREATMENT

Is your patient currently taking?

FUNCTIONAL STATUS
Has the stroke left your patient with any problems? Do they need help from anybody with everyday activities?
(i.e. walking, dressing, washing, feeding or toileting) In the next section we would like your patient to read the following descriptions and
choose the one which best describes their present state. If your patient cannot read or
complete the questionnaire, please complete it on their behalf.

I have a few symptoms but these do not interfere with my everyday life I have symptoms which have caused some changes in my life but I am still I have symptoms which have significantly changed my life and I need some I have quite severe symptoms which mean I need to have help from other people but I am not so bad as to need attention day and night I have major symptoms which severely handicap me and I need constant By placing a tick () in one box in each group below, please indicate which statements
best describe your patients health state today.
Mobility

I have no problems in walking about

Self-Care
I have no problems with self care
I have some problems with washing or dressing myself
Usual Activities
I have no problems with performing my usual activities
I have some problems with performing my usual activities I am unable to perform my usual activities
Pain/discomfort
I have no pain or discomfort

Anxiety/depression
I am not anxious or depressed
Name of person completing form: _______________________Date of form completion ___/___/___(dd/mm/yyyy) Thank you very much for taking the time to complete this form
Please FAX it to us or return it using the pre-paid envelope provided.

Source: http://www.dcn.ed.ac.uk/clots/clots_orig/clot_orig_forms/In%20hospital%20followup05.pdf

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