Personal history

1) Do you think you have ever had deep vein thrombosis?

If yes: at what age ?

2) Have you ever been admitted to hospital for pulmonary embolism?

If yes: at what age?

3) Even if the answer is negative to the above questions, do you remember that a physician ever diagnosed you as having :

a) thrombosis, phlebitis, thrombophlebitis

of the veins in the legs

of the veins in other sites of the body ( arms, neck or liver, for example)

b) pulmonary embolism/thrombosis of the veins in the lung

c) post-phlebitic syndrome

Only if the answer at one of the previous questions has been yes:

4) Do you remember whether you ever were given therapy with subcutaneous injections, on the abdomen or the arms, to make your blood more fluid?

5) Do you remember whether you ever took pills to make your blood fluid and that required periodic (every 10-15 days) blood tests to determine the right number of pills you had to take?

Family history

1) Do you remember whether your parents or any one of your brothers, sisters, sons or daughters were ever diagnosed as having deep vein thrombosis?

If yes: please indicate which relative(s) and at what age

2) Do you remember whether your parents or any one of your brothers, sisters, sons or daughters were ever admitted to hospital for pulmonary embolism?

If yes: please indicate which relative(s) and at what age

3) Do you remember whether your parents or any one of your brothers, sisters, sons or daughters were ever diagnosed as having:

a) thrombosis, phlebitis, thrombophlebitis

of the veins in the legs

of the veins in other sites of the body ( arms, neck or liver, for example)

b) pulmonary embolism/thrombosis of the veins in the lung

c) post-phlebitic syndrome

If yes, please indicate which relative(s) and at what age