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Assessment of Knowledge in Patients Taking Oral Anticoagulants
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
Age
Select one answer
18_30
31_40
41_50
>50
2
Gender
Select one answer
Male
Female
3
Residence
Select one answer
Rural
Urban
4
Occupation
Select one answer
Unemployed
Private
Govermental
Other (please specify)
5
Educational level
Select one answer
Illiterate
Primary
Secondary
University
Postgraduate
6
Marital status
Select one answer
Single
Married
Divorced
Widowed
7
Family income
Select one answer
High
Medium
Low
8
Health insurance
Select one answer
Yes
No
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9
Family history of cardiovascular disease
Select one answer
Yes
No
10
Disease duration
Select one answer
1_2 yrs
3_5 yrs
6_10 yrs
>10 yrs
11
Comorbedeties
Select one answer
Renal failure
Liver failure
Hypertension
Diabetes
COPD
Other (please specify)
12
Smoking
Select one answer
Yes
No
13
Alcoholic
Select one answer
Yes
No
14
Follow up pattern
Select one answer
Regular
Irregular
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15
Name of anticoagulant drug
Select one answer
Warfarin
Rivaroxaban
Dabigatran
16
What is the dose of this medication
17
What is the indication of this medication
Select one answer
AF
DVT/PE
Prosthetic heart valve
Other (please specify)
18
Duration of treatment with anticoagulant drugs
Select one answer
<3 monthes
3_11 monthes
1_2 years
>2 years
19
If you missed a dose of your blood thinning medicine and it was time for your next dose what would you do
Select one answer
Stop taking the medication
Take two doses to catch up from the missed dose
Skip the missed dose and take the next scheduled dose
20
Would you inform a surgeon, dentist or other healthcare professionals that you are taking oral anticoagulants before undergoing surgery or procedure
Select one answer
Yes
No
21
Which of the following would be a reason to visit an emergency room
Select one answer
None
Waking up with bad dreams and a dry mouth
Noticing a large amount of bright red blood in the last 2 bowel movements
Seeing tiny streaks of blood in the sink after brushing your teeth
22
What is the major side effects of anticoagulant drugs
Select one or more answers
Bleeding
Urination
Headache
Bruising
23
How to stop bleeding if occurs
Select one or more answers
Put pressure on any cuts for few minutes
Call your doctor
Not fixed
24
Food that interact with anticoagulant drugs
Select one answer
green leafy vegetables
Dairy products
None
25
Drug that interact with anticoagulant drug
Select one or more answers
Drugs that affect p_gp enzyme
NSAIDs
Vitamin K antagonist
None
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26
Do you sometimes forget to take your prescribed medications?
Select one answer
Yes
No
27
Have you stopped taking medications because you feel worse when you took it?
Select one answer
Yes
No
28
When you feel like your health under control do you sometimes stop taking your medics?
Select one answer
Yes
No
29
How do you monitor the effectiveness of oral anticoagulant therapy?
Please provide your answer.
30
What is the target INR range?
Select one answer
2_3
2.5_3.5
Above 4.9
Not fixed
31
Increase INR value above target range has negative effect on health
Select one answer
Yes
No
32
Decrease INR value below target range has negative effect on health
Select one answer
Yes
No
33
How often should blood tests be done when taking oral anticoagulants?
Please select the appropriate frequency.
Monthly
Quarterly
Yearly
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