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Warfarin Monitoring

Name:                                                                                   Date of Birth:

Indication for Warfarin

(Please tick one)

Atrial Fibrillation


Pulmonary Thromboembolism


Personal history with Deep Vein Thrombosis



Please state




Therapeutic Target Range


Date of Last INR


INR Result


Date INR is next due


Any Reasons why dosing was changed recently?

e.g. Antibiotic Use etc…