League City Family Clinic

Are you a Texas Resident? *

Do you have a history of clotting events including heart attacks, strokes, pulmonary embolisms, and DVTs? *

Yes

No

Unsure

Do you have a history of heart disease including heart failure? *

Yes

No

Unsure

Do you have a history of severe liver or kidney disease? *

Yes

No

Unsure

Do you have a history of elevated hemoglobin, hematocrit, or red blood cells on previous blood work or history of thrombophilia? *

Yes

No

Unsure

Do you have a history of prostate cancer or an elevated prostate-specific antigen (greater than 4ng/mL)? *

Yes

No

Unsure