Please copy and paste this form and e-mail to rushden.k83024@nhs.net

Warfarin Monitoring

Name:                                                                                   Date of Birth:

Indication for Warfarin

(Please tick one)

Atrial Fibrillation

 

Pulmonary Thromboembolism

 

Personal history with Deep Vein Thrombosis

 

Other

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…