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Table 3 Modified questionnaire for thrombosis risk based on Friedman et al.

From: Successful microvascular surgery in patients with thrombophilia in head and neck surgery: a case series

 

Yes

No

Have you or has anyone in your family ever had a blood clot?

  

Have you or has anyone in your family ever been diagnosed with a blood clotting disorder?

  

For female patients: have you ever had a miscarriage?