Anticoagulant questionnaire

Anticoagulant questionnaire

You have been asked to complete this annual review questionnaire as you are prescribed an anticoagulant medication (Apixaban, Edoxaban or Rivaroxaban)

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Anticoagulant Review

    Do you know why you are prescribed your anticoagulant medication? (optional)
    Would you be interested in receiving more information about your medication? (optional)
    Do you always remember to take your medicine as prescribed? (optional)
    Are you aware of what to do if you miss a dose of your medicine? (optional)

  • Consent

    Thank you for completing this questionnaire. You may be contacted to organise an appointment for a blood test and blood pressure checks as part of the annual review.

    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, AND OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA

  • Further Information

    For further information on anticoagulants please visit: Click Here

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Page last reviewed: 23 June 2025
Page created: 19 June 2025