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ADVANCED SURGICAL GROUP

Patient’s Name:(Required)

Age:

Gender:

Height:

Weight:

BMI:

Each Risk Factor Represents 1 Point

Each Risk Factor Represents 2 Points

Age 61-74 years

Major surgery planned >1 hour

History of cancer

*Recent laparoscopic surgery

BMI>40

*Recent leg plaster cast or brace

Bed rest >72 hours

Central venous access

Women only:

Oral contraceptives or hormone replacement therapy

Pregnant or <1 month postpartum

History of unexplained stillborn or miscarriages, premature birth with toxemia or growth-restricted infant

Each Risk Factor Represents 3 Points

Age 75 or over

Major surgery lasting 2-3 hours

BMI >50

History of blood clots including DVT/PE

History or family history of a blood clotting disorder (e.g.-Factor V Leiden)

Positive Lupus anticoagulant

Heparin-induced thrombocytopenia (HIT)

Other thrombophilia_______________________

Each Risk Factor Represents 5 Points

*Recent hip or knee replacement Surgery or arthroplasty

*Recent hip, pelvis or leg fracture

*Recent stoke

*Recent trauma (e.g.-fall, car accident, broken bone, spinal injury)

Major surgery lasting over 3 hours

Total Risk Factor Score	Risk Level	Incidence of DVT	Suggested Prophylaxis Regime – Dependent of Physician’s Orders
0-1	Low	2%	Early ambulation
2	Moderate	10-20%	Early ambulation, ankle pumps, compression stockings
3-4	Higher	20-40%	Early & frequent ambulation, ankle pumps, compression stockings or SCD
5+	Highest	40-80%	Early & frequent ambulation, ankle pumps, compression stockings or SCD, chemical prophylaxis, post-discharge prophylaxis.