Anticoagulant Questionnaire

As you are on an anticoagulant (blood thinner), guidelines advise you have an annual review to ensure your safety whilst on this medication. You will also have a blood test to monitor your blood count, kidney and liver function. It is very important you have your blood test taken when advised.

If you are having problems with your anticoagulant, please request an appointment.

Anticoagulant Questionnaire

Anticoagulant Questionnaire


If you're taking warfarin and you miss one of your doses, you should skip the dose you missed and wait to take your next scheduled dose as normal. Don't take a double dose to make up for the one you missed.

Inform the clinician at your next INR appointment.


Please select which anticoagulant you are taking:
Do you smoke?

Compliance to Medication

Please choose as appropriate:

Alcohol Questions

We recommend that you do not exceed the safe limits of alcohol (14 units for men and women per week), as this can increase your risk of bleeding.
Do you regularly drink more than the recommended safe alcohol limits?

Support can be accessed from this website at


Please read our Anticoagulation Advice page before submitting this form.