WARFARIN Study
RequiredRequired Question(s)
Progress: 
  

Tell Us About Your Facility:

 
Required 4.

Address (including web address):

 

350 characters left.
Required 5.

Select the closest description to your facility type:

Don't know / I am unsure
Single Hospital (Private)
Single Hospital (Public)
Single Hospital (University Affiliated
Multiple Hospital System
VA or Military Hospital
Anti-Coagulation Clinic
Single Payor Entity (e.g. HMO)
Medical School Affiliated with a Single Hospital
Medical School affiliated with Multiple Hospitals
Other  
Required 6.

Briefly describe the facility (size, location, population served, number of potential participating clinics / sites):

 

1000 characters left.
Required 7.

How many new start prescriptions for warfarin are written each month?

1-20
21-50
51-100
101-200
201+
Don't know / I am unsure
Required 8.

Are subjects that are prescribed warfarin followed in a central warfarin clinic?

Yes
No
Don't know / I am unsure
Required 9.

Do you have access to follow these subjects for 3 months?

Yes
No
Required 10.

Are subjects that are prescribed warfarin followed in a primary care clinic (associated with facility)?

Yes
No
Don't know / I am unsure
Required 11.

What are the most common diagnoses that result in warfarin prescriptions?  Please check all that apply:

Thrombosis
Pulmonary Embolism
Atrial Fibrillation
Antiphospholipid Syndrome
Myocardial Infarction
Deep Venous Thrombosis (DVT)
Arterial Graft Thrombosis
Arterial Thrombosis
Rheumatic Mitral Valve Disease
Congestive Heart Failure
Hypercoagulable State
Mural Thrombus
Stroke Prevention
Don't know / I am unsure
Other  
Required 12.

What percentage of warfarin perscriptions are written for Medicare patients?

<10%
10-25%
25-50%
>50%
Don't know / I am unsure