Report treatment of the most severe episode

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AVERAGE PRESENTATION

# of episodes

Type of bleeding

Hematemesis Melena Hematochezia

Presence of associated GI disease

Yes                                               No

Gastritis/ulcer Colitis

Mallory-Weiss tear Vascular malformations Other

REPORT TREATMENT OF THE MOST SEVERE EPISODE

Required medical attention?

If yes, please specify:

Yes

No

Consultation only Surgical hemostasis Antifibrinolytics Desmopressin Replacement therapy Blood transfusion

# of times

# of times

# of times

# of times

# of times

Notes

Surgery                 No            If Yes,

Trivial         Significant

Significant: Any bleeding stated as abnormally prolonged by the surgeon OR causing a delay in discharge OR requiring some supportive treatment.

Total # of surgeries

Specify

# of surgeries followed by bleeding

MOST SEVERE OCCURRENCE

Age at surgery

Type of surgery

Specify

Prophylaxis before surgery?

Bleeding after surgery?

Yes

Actions taken to control bleeding

Notes

Menorrhagia                  N/A

No

Yes

Duration of average menstruation (days)

Duration of heavy (days)

How often do you change your pads/tampons

on heaviest days

         hours

on average days

         hours

What type of feminine product do you use? (i.e. panty liner, super absorbency tampon etc.)

Comments

MOST SEVERE PRESENTATION

Age of maximum severity

 8-12

 13-16

 17-20

>20 yrs

Required medical attention?

If yes, please specify:

Yes

No

Consultation only Pill use Antifibrinolytics

Dilatation & curettage Iron therapy Desmopressin Replacement therapy Blood transfusion Hysterectomy

# of times

# of times

Notes

Post-partum hemorrhage

No   N/A

If Yes,  Trivial      Significant

Significant: Any bleeding stated as abnormally prolonged by the obstetrician OR causing a delay in discharge OR requiring some supportive treatment.

Total # of deliveries

# of deliveries  followed by bleeding

MOST SEVERE OCCURRENCE

Age at delivery

Mode of delivery

spontaneous assisted

c-section

Prophylaxis before delivery

None Antifibrinolytics Desmopressin

Replacement therapy

Bleeding after delivery?

Yes

No

Actions taken to control bleeding

None Consultation only

Resuturing/surgical Antifibrinolytics Desmopressin Replacement therapy Blood transfusion

Hysterectomy

Notes

Muscle hematomas       No             Yes

(N.B.: All muscle hematomas are considered to be significant.)

Total #

MOST SEVERE PRESENTATION

Please specify type & location

Post-trauma?

Yes                                               No

Prophylaxis?

None Antifibrinolytics Desmopressin

Replacement therapy

Required medical attention

If yes, please specify:

?                 Yes                                               No

Surgical intervention Desmopressin Replacement therapy Blood transfusion

Notes

Hemarthrosis                 No            Yes

(N.B.: All episodes of hemarthrosis are considered to be significant.)

Total #

MOST SEVERE PRESENTATION

Please specify type & location

Post-trauma?

Yes                                               No

Prophylaxis?

None Antifibrinolytics Desmopressin

Replacement therapy

Required medical attention?

If yes, please specify:

Yes                                               No

Surgical intervention Desmopressin Replacement therapy Blood transfusion

Notes

Other bleeding        No

Yes

(N.B.: All episodes of any of these bleeding symptoms are considered to be significant.)

If yes, type of bleeding Umbilical stump

Bleeding at circumcision Male, not circumcised  Male, circumcised

Female

Conjunctival hemorrage

Cephalohematoma       Venipuncture bleed

Hematuria, macroscopic

ing 

MOST SEVERE PRESENTATION

Please specify type

Required medical attention?

Yes

No

If yes, please specify:

Consultation only

Iron therapy

# of times

Surgical hemostasis

# of times

Antifibrinolytics

# of times

Desmopressin

# of times

Replacement therapy

# of times

Blood transfusion

# of times

Notes

MOST SEVERE PRESENTATION

Please specify type

Required medical attention?

If yes, please specify:

Yes

No

Consultation only Iron therapy Surgical hemostasis Antifibrinolytics Desmopressin

Replacement therapy Blood transfusion

Notes

# of times

# of times

# of times

# of times

# of times

# of times

Pediatric Bleeding Questionnaire (PBQ)

Score

-1

Symptom

Epistaxis

-

No or trivial (≤5 per year)

>5 per year OR >10 minutes duration

Consultation only

Packing, cauterization or antifibrinolytics

Blood transfusion, replacement therapy or desmopressin

Cutaneous

-

No or trivial (≤1cm)

>1cm AND no trauma

Consultation only

-

-

Minor wounds

-

No or trivial (≤5 per year)

>5 per year OR >5 minutes duration

Consultation only or Steri-strips

Surgical hemostasis or antifibrinolytics

Blood transfusion, replacement therapy or desmopressin

Oral cavity

-

No

Reported at least once

Consultation only

Surgical hemostasis or antifibrinolytics

Blood transfusion, replacement therapy or desmopressin

Gastrointestinal tract

-

No

Identified cause

Consultation or spontaneous

Surgical hemostasis, antifibrinolytics, blood transfusion, replacement therapy or desmopressin

-

Tooth extraction

No bleeding in at least 2 extractions

None done or no bleeding in 1 extraction

Reported, no consultation

Consultation only

Resuturing, repacking or antifibrinolytics

Blood transfusion, replacement therapy or desmopressin

Surgery

No bleeding in at least 2 surgeries

None done or no bleeding in 1

Reported, no consultation

Consultation only

Surgical hemostasis or antifibrinolytics

Blood transfusion, replacement therapy or desmopressin

Menorrhagia

-

No

Reported or consultation only

Antifibrinolytics or contraceptive pill use

D&C or iron therapy

Blood transfusion, replacement therapy, desmopressin or hysterectomy

Post-partum

No bleeding in at least 2 deliveries

No deliveries or no bleeding in 1 delivery

Reported or consultation only

D&C, iron therapy or antifibrinolytics

Blood transfusion, replacement therapy or desmopressin

-

Muscle hematoma

-

Never

Post-trauma, no therapy

Spontaneous, no therapy

Spontaneous or traumatic, requiring replacement therapy or desmopressin

Spontaneous or traumatic, requiring surgical intervention or blood transfusion

Hemarthrosis

-

Never

Post-trauma, no therapy

Spontaneous, no therapy

Spontaneous or traumatic, requiring replacement therapy or desmopressin

Spontaneous or traumatic, requiring surgical intervention or blood transfusion

Central nervous system

-

Never

-

-

Subdural, any intervention

Intracerebral, any intervention

Other

Post-circumcision Umbilical stump Cephalohematoma Macroscopic hematuria Post-venepuncture Conjunctival hemorrage

-

No

Reported

Consultation only

Surgical hemostasis, antifibrinolytics or iron therapy

Blood transfusion, replacement therapy or desmopressin

August 16, 2010 (Revised for clinical use)                                                  Page 13of 13

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