Quality of life | I have felt unwell because of my bleeding disorder | 9 | 2 | 0 | 0 | 0 | 0 | 0 |
I have missed work or school because of bleeding problems | 9 | 2 | 0 | 0 | 0 | 0 | 0 | |
I have missed 2 or more days of work/school per month because of bleeding problems | 11 | 0 | 0 | 0 | 0 | 0 | 0 | |
I limit my activities because of bleeding problems | 10 | 0 | 1 | 0 | 0 | 0 | 0 | |
Bleeding problems | I have visited the emergency department for bleeding problems | 9 | 2 | 0 | 0 | 0 | 0 | 0 |
I have visited my doctor for bleeding problems | 9 | 2 | 0 | 0 | 0 | 0 | 0 | |
I have nosebleeds that last longer than 10 minutes | 9 | 1 | 0 | 1 | 0 | 0 | 0 | |
I can manage nosebleeds on my own | 3 | 0 | 1 | 1 | 5 | 1 | 0 | |
I need to have treatment with medication for nosebleeds | 7 | 0 | 0 | 0 | 0 | 4 | 0 | |
I have spontaneous nosebleeds | 5 | 0 | 2 | 2 | 1 | 1 | 0 | |
If so, how often | 0 | 0 | 0 | 1 | 1 | 4 | 5 | |
Dental problems | I have bleeding around my teeth and gums | 7 | 3 | 1 | 0 | 0 | 0 | 0 |
I have prolonged bleeding from biting my mouth and tongue | 9 | 2 | 0 | 0 | 0 | 0 | 0 | |
I have bleeding complications with dental work | 10 | 0 | 1 | 0 | 0 | 0 | 0 | |
GI and urinary problems | I have bleeding from my rectum | 10 | 1 | 0 | 0 | 0 | 0 | 0 |
I have vomited blood | 11 | 0 | 0 | 0 | 0 | 0 | 0 | |
I have had vomit that looked like coffee grounds | 11 | 0 | 0 | 0 | 0 | 0 | 0 | |
I have had unexplained stomach pain | 10 | 1 | 0 | 0 | 0 | 0 | 0 | |
I have had bleeding after a colonoscopy | 11 | 0 | 0 | 0 | 0 | 0 | 0 | |
I have had blood in my urine | 11 | 0 | 0 | 0 | 0 | 0 | 0 | |
If so, how often | 0 | 0 | 0 | 0 | 0 | 0 | 11 |
For female patients (N=6) | My periods last longer than 7 days | 1 | 1 | 0 | 0 | 0 | 5 | 4 |
My periods are less than 28 days apart | 1 | 0 | 0 | 0 | 1 | 5 | 4 | |
I pass clots during my period | 1 | 1 | 0 | 0 | 0 | 5 | 4 | |
I have to change pads every 2 hours or less because of bleeding | 1 | 0 | 0 | 0 | 1 | 5 | 4 | |
I have to change pads/tampons at night | 1 | 0 | 0 | 0 | 1 | 5 | 4 | |
I have to wear double pads | 1 | 0 | 0 | 1 | 0 | 5 | 4 | |
I saturate my clothes | 1 | 0 | 0 | 1 | 0 | 5 | 4 | |
Sexual activity | I have had bleeding after sexual activity | 1 | 0 | 1 | 0 | 0 | 4 | 5 |
Energy levels | I feel frequently tired or fatigued | 1 | 3 | 3 | 1 | 0 | 2 | 1 |
I have difficulty concentrating | 2 | 3 | 2 | 1 | 0 | 2 | 1 | |
Family and friends describe me as irritable | 3 | 2 | 3 | 0 | 0 | 2 | 1 | |
I eat a vegetarian diet | 8 | 0 | 0 | 0 | 0 | 2 | 1 | |
I have difficulty sleeping | 2 | 2 | 2 | 0 | 2 | 2 | 1 | |
I have felt the need to take iron supplements | 5 | 2 | 0 | 1 | 0 | 2 | 1 | |
I have felt sad or depressed | 2 | 1 | 3 | 1 | 1 | 2 | 1 | |
I have cancelled plans because of lack of energy | 6 | 1 | 1 | 0 | 0 | 2 | 1 | |
Current medications | Please list your current medications including any herbal products or medications without a prescription | 1 | 0 | 0 | 0 | 0 | 6 | 0 |
Medications listed | Laxaday (laxative), APO Paroxatine, APO Lorazapam, Dixilant (60mg) QD, Rosuvastatin (10mg) QD, Ramiptril (2.5mg) QD, Zopidone (7.5mg) QD, Sertraline (50mg) QD and Lorazepam (1mg) BID when needed, high blood pressure meds |