Table 7.

Antithrombotic therapy form (refer to Antithrombotic Therapy Dictionary)

Date antithrombotic therapy form completed (MM/DD/YYYY): ________________ 
Indicate patient’s most recent documented or reported weight at the time of thrombotic event: __________ kg, OR __________ lb, OR ☐ unknown 
Height __________ cm, OR __________ inches, OR ☐ unknown 
Section 1: Anticoagulant treatment: ☐ No ☐ Yes (indicate the type, dose, and frequency below) 
 ☐ Low-molecular-weight heparin Drug Dose  Frequency 
 ☐ Enoxaparin __________ ☐ mg
☐ mg/kg
☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Dalteparin __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Tinzaparin __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Nadroparin __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Certoparin __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Bemiparin __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Other (specify):________ __________ ☐ mg
☐ mg/kg
☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Unfractionated heparin (indicate method of administration and dose, frequency): Route of administration Dose  Frequency 
 ☐ Intravenous infusion __________ Units/kg/h Continuous infusion 
 ☐ Subcutaneous __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Fondaparinux (indicate dose and frequency): Dose Frequency  
 ________ mg ☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 		   
 ☐ Direct oral anticoagulants (indicate drug, dose, frequency): Drug Dose and frequency    
 ☐ Apixaban ☐ 2.5 mg twice daily
☐ 5 mg twice daily
☐ 10 mg twice daily
☐ Other (specify):________ 		   
 ☐ Rivaroxaban ☐ 2.5 mg twice daily
☐ 10 mg once daily
☐ 15 mg once daily
☐ 15 mg twice daily
☐ 20 mg once daily
☐ Other (specify):________ 		   
 ☐ Edoxaban ☐ 30 mg once daily
☐ 60 mg once daily
☐ Other (specify):________ 		   
 ☐ Dabigatran ☐ 75 mg twice daily
☐ 110 mg twice daily
☐ 150 mg twice daily
☐ 220 mg once daily
☐ Other (specify):________ 		   
 ☐ Vitamin K antagonist (indicate drug and target INR): Drug Target INR    
 ☐ Warfarin
☐ Phenprocoumon
☐ Acenocoumarol
☐ Fluindione
☐ Other (specify): _______________
☐ Unknown 		☐ INR 1.5 to 2.5
☐ INR 2 to 3
☐ INR 2.5 to 3.5
☐ Other (specify): _____________________
☐ Unknown 		   
 ☐ Unknown anticoagulant      
 ☐ Other anticoagulant not listed above (specify below): Drug Dose  Route Frequency 
 Argatroban __________ ☐ μg/kg/min
☐ Other (specify): ______ 		Intravenous ☐ Continuous infusion
☐ Other (specify):________ 
 Bivalirudin __________ ☐ mg/kg/h
☐ Other (specify): _______ 		Intravenous ☐ Continuous infusion
☐ Other (specify):________ 
 Other (specify): _______________ __________ ☐ mg
☐ mg/kg
☐ mg/kg/h
☐ units
☐ units/kg
☐ μg/kg/min 		☐ Oral
☐ Subcutaneous   
☐ Intravenous 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Continuous infusion
☐ Other (specify):________ 
Section 2: Antiplatelet therapy: ☐ No ☐ Yes (indicate the type, dose, and frequency below)     
 ☐ Aspirin (acetylsalicylic acid) ☐ Low dose (≤100 mg daily)
☐ 325 mg once daily
☐ Other (specify): _____________ 		    
 ☐ Clopidogrel ☐ 75 mg once daily
☐ 150 mg once daily 		    
 ☐ Ticagrelor ☐ 60 mg twice daily
☐ 90 mg twice daily 		    
 ☐ Prasugrel ☐ 5 mg once daily
☐ 10 mg once daily 		    
 ☐ Acetylsalicylic acid and dipyridamole ER ☐ Aspirin 25 mg/dipyridamole ER 200 mg twice daily
☐ Aspirin 25 mg/dipyridamole ER 200 mg once daily 		   
 ☐ Cangrelor ☐ 30 μg/kg bolus then 4 μg/kg/min (for percutaneous intervention)
☐ 0.75 μg/kg/min (for bridging therapy before cardiac surgery) 		   
 ☐ Other antiplatelet therapy, including nonsteroidal anti-inflammatory drugs (specify below): Dose  Route Frequency 
 ________ ☐ mg
☐ units
☐ Other (specify): ________ 		☐ Oral
☐ Subcutaneous
☐ Intravenous 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Continuous infusion
☐ Other (specify):________ 
 ________ ☐ mg
☐ units
☐ Other (specify): ________ 		☐ Oral
☐ Subcutaneous
☐ Intravenous 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Continuous infusion
☐ Other (specify):________ 
Section 3: Mechanical thromboprophylaxis: ☐ No ☐ Yes (indicate the type below)     
 ☐ Intermittent pneumatic compression
☐ Graduated compression stockings
☐ Antiembolism stockings
☐ Other (specify): 		     
Date antithrombotic therapy form completed (MM/DD/YYYY): ________________ 
Indicate patient’s most recent documented or reported weight at the time of thrombotic event: __________ kg, OR __________ lb, OR ☐ unknown 
Height __________ cm, OR __________ inches, OR ☐ unknown 
Section 1: Anticoagulant treatment: ☐ No ☐ Yes (indicate the type, dose, and frequency below) 
 ☐ Low-molecular-weight heparin Drug Dose  Frequency 
 ☐ Enoxaparin __________ ☐ mg
☐ mg/kg
☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Dalteparin __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Tinzaparin __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Nadroparin __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Certoparin __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Bemiparin __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Other (specify):________ __________ ☐ mg
☐ mg/kg
☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Unfractionated heparin (indicate method of administration and dose, frequency): Route of administration Dose  Frequency 
 ☐ Intravenous infusion __________ Units/kg/h Continuous infusion 
 ☐ Subcutaneous __________ ☐ units
☐ units/kg 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 
 ☐ Fondaparinux (indicate dose and frequency): Dose Frequency  
 ________ mg ☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Other (specify):________ 		   
 ☐ Direct oral anticoagulants (indicate drug, dose, frequency): Drug Dose and frequency    
 ☐ Apixaban ☐ 2.5 mg twice daily
☐ 5 mg twice daily
☐ 10 mg twice daily
☐ Other (specify):________ 		   
 ☐ Rivaroxaban ☐ 2.5 mg twice daily
☐ 10 mg once daily
☐ 15 mg once daily
☐ 15 mg twice daily
☐ 20 mg once daily
☐ Other (specify):________ 		   
 ☐ Edoxaban ☐ 30 mg once daily
☐ 60 mg once daily
☐ Other (specify):________ 		   
 ☐ Dabigatran ☐ 75 mg twice daily
☐ 110 mg twice daily
☐ 150 mg twice daily
☐ 220 mg once daily
☐ Other (specify):________ 		   
 ☐ Vitamin K antagonist (indicate drug and target INR): Drug Target INR    
 ☐ Warfarin
☐ Phenprocoumon
☐ Acenocoumarol
☐ Fluindione
☐ Other (specify): _______________
☐ Unknown 		☐ INR 1.5 to 2.5
☐ INR 2 to 3
☐ INR 2.5 to 3.5
☐ Other (specify): _____________________
☐ Unknown 		   
 ☐ Unknown anticoagulant      
 ☐ Other anticoagulant not listed above (specify below): Drug Dose  Route Frequency 
 Argatroban __________ ☐ μg/kg/min
☐ Other (specify): ______ 		Intravenous ☐ Continuous infusion
☐ Other (specify):________ 
 Bivalirudin __________ ☐ mg/kg/h
☐ Other (specify): _______ 		Intravenous ☐ Continuous infusion
☐ Other (specify):________ 
 Other (specify): _______________ __________ ☐ mg
☐ mg/kg
☐ mg/kg/h
☐ units
☐ units/kg
☐ μg/kg/min 		☐ Oral
☐ Subcutaneous   
☐ Intravenous 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Continuous infusion
☐ Other (specify):________ 
Section 2: Antiplatelet therapy: ☐ No ☐ Yes (indicate the type, dose, and frequency below)     
 ☐ Aspirin (acetylsalicylic acid) ☐ Low dose (≤100 mg daily)
☐ 325 mg once daily
☐ Other (specify): _____________ 		    
 ☐ Clopidogrel ☐ 75 mg once daily
☐ 150 mg once daily 		    
 ☐ Ticagrelor ☐ 60 mg twice daily
☐ 90 mg twice daily 		    
 ☐ Prasugrel ☐ 5 mg once daily
☐ 10 mg once daily 		    
 ☐ Acetylsalicylic acid and dipyridamole ER ☐ Aspirin 25 mg/dipyridamole ER 200 mg twice daily
☐ Aspirin 25 mg/dipyridamole ER 200 mg once daily 		   
 ☐ Cangrelor ☐ 30 μg/kg bolus then 4 μg/kg/min (for percutaneous intervention)
☐ 0.75 μg/kg/min (for bridging therapy before cardiac surgery) 		   
 ☐ Other antiplatelet therapy, including nonsteroidal anti-inflammatory drugs (specify below): Dose  Route Frequency 
 ________ ☐ mg
☐ units
☐ Other (specify): ________ 		☐ Oral
☐ Subcutaneous
☐ Intravenous 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Continuous infusion
☐ Other (specify):________ 
 ________ ☐ mg
☐ units
☐ Other (specify): ________ 		☐ Oral
☐ Subcutaneous
☐ Intravenous 		☐ Every 24 h
☐ Every 12 h
☐ Every 8 h
☐ Continuous infusion
☐ Other (specify):________ 
Section 3: Mechanical thromboprophylaxis: ☐ No ☐ Yes (indicate the type below)     
 ☐ Intermittent pneumatic compression
☐ Graduated compression stockings
☐ Antiembolism stockings
☐ Other (specify): 		     

ER, extended release; INR, international normalized ratio.

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