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ENT: Bleeding history questionnaire

If patient gives an affirmative answer concerning coagulation or family history, consider referral to a hematologist.

Medication and treatment

  • Are you currently receiving or have you recently
    - Antiplatelet or anti-coagulation medication,
      such as aspirin, clopidogrel, marcumar, valproic
      acid or warfarin?
    - Non-steroidal anti-inflammatory drugs:
      diclofenac, ibuprofen?
    - Antibiotic medication: penicillin, tetracycline,
      sulfonamides, fluoroquinolones (eg,
    - Other drugs that interact with the coagulation
      system: valproic acid, megadoses of vitamin E?
  • Have you ever had anemia that required
    treatment, or have you ever received a blood


  • Have you ever had a spontaneous nosebleed
    that either persisted for 10 minutes or required
    medical attention?
  • Have you ever experienced prolonged
    bleeding (duration of 15 minutes,
    or spontaneous recurrence within seven
    days) from minor wounds?
  • Women only: Have you ever had heavy
    menstrual bleeding where you needed to
    change a pad or a tampon more than hourly?
  • Have you ever experienced heavy prolonged
    or recurrent bleeding following a surgical

Family History

  • Women only: Do other women in your family
    suffer from heavy menstrual bleeding?
  • Do any of your blood relatives regularly
    experience any of the 5 Signs of Bleeding?
  • Have you ever experienced heavy prolonged or
    recurrent bleeding after minor or major surgical
    procedures, such as dental extractions or

For further information select one of the following links: Coagulation Cascade, Coagulation Disorders, Resources or Useful Links
To download the brochure see "Resources" or Print the questionnaire

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