Thrombosis Risk Factor Assessment
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EACH RISK FACTOR REPRESENTS 1 POINT (Choose all that apply)
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Other Risk Factors:
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EACH RISK FACTOR REPRESENTS 2 POINTS (Choose all that apply)
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EACH RISK FACTOR REPRESENTS 3 POINTS (Choose all that apply)
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If "Other congenital or acquired thrombophilia" selected, please explain:
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EACH RISK FACTOR REPRESENTS 5 POINTS
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FOR WOMEN ONLY (EACH REPRESENTS ONE POINT)
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Total Risk Factor Score
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Patient Weight
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