TABLE 2.

Thrombosis risk factor assessment.

Patient’s Name:________________________________________________________________________ Age:_________________________________________________________________________________ Sex:_________________________________________________________________________________
Each risk factor represents 1 point	Each risk factor represents 2 points
□ Abnormal pulmonary function (COPD); □ Acute myocardial infarction; □ Age between 41 and 59 years; □ Blood transfusions; □ Chemotherapy; □ Congestive heart failure (<1 month); □ Diabetes requiring insulin; □ History of inflammatory bowel disease; □ History of prior major surgery (<1 month); □ Length of a surgery > 2 h; □ Medical patient currently on bed rest; □ Minor surgery planned; □ BMI > 25–39; □ Obstructive pulmonary disease; □ Sepsis (<1 month); □ Serious lung disease including pneumonia (<1 month); □ Smoking; □ Swollen legs (current); □ Varicose veins; □ Other risk factors: easy bruising, for example, must be included as may represent a platelet disorder (Ballas and Kraut, 2008);	□ Age 60–74 years; □ Arthroscopic surgery; □ BMI > 40; □ Central venous access; □ Immobilized plaster cast (<1 month); □ Laparoscopy surgery (>45 min); □ Major surgery (>45 min); □ Malignancy (present or previous); □ Patient confined to bed (>72 h);
Each risk factor represents 3 points	Each risk factor represents 5 points
□ Age over 75 years; □ Any acquired congenital thrombophilia; □ Elevated anticardiolipin antibodies; □ Elevated serum homocysteine; □ Family history of thrombosis; □ Heparin-induced thrombocytopenia; □ History of DVT/PE; □ Positive Factor V Leiden; □ Positive lupus anticoagulant; □ Positive Prothrombin 20210A; □ If the answer is yes: □ Type:___________________________	□ Acute spinal cord injury (paralysis) (<1 month); □ Elective major lower extremity arthroplasty; □ Hip, pelvis or leg fracture (<1 month); □ Multiple trauma (<1 month); □ Stroke (<1 month);
For women only (each represents 1 point)	Total risk factor score
□ History of unexplained stillborn infant, recurrent spontaneous abortion (≥3), premature birth with toxemia, or growth-restricted infant; □ Oral contraceptives or hormone replacement therapy; □ Pregnancy or postpartum (<1 month);	Score	Incidence of DVT	Risk level
	0–1	<10%	Low
	2	10–20%	Moderate
	3–4	20–40%	High
	5 or more	40–80% and risk of mortality of 1–5%	Highest

Adapted from Caprini (2005). DVT, deep vein thrombosis; PE, pulmonary embolism; BMI, body mass index; COPD, chronic obstructive pulmonary disease.