Alere Home Monitoring, Inc. Patient Survey

First Name: *

Last Initial: *

Age: *

Are you a warfarin patient or the caregiver of a warfarin patient?: *

Warfarin patient

Caregiver of warfarin patient

Why I’m on warfarin: *

Heart Valve

Atrial Fibrillation

DVT/PE (clot in leg or lung)

Other

Blood is taken: *

Lab

Clinic/office

Home

My INR is checked: *

Monthly

Weekly

Bi-weekly

I am comfortable taking warfarin: *

From 1 being not at all comfortable, to 10 being completely comfortable

My feel in control of my INR: *

From 1 being not at all in control, to 10 being completely in control

I am comfortable with the method used to test my blood: *

From 1 being not at all comfortable, to 10 being completely comfortable

Am in my target range: *

10% of the time

20% of the time

30% of the time

40% of the time

50% of the time

60% of the time

70% of the time

80% of the time

90% of the time

100% of the time

I am confident being on warfarin: *

From 1 being not at all confident, to 10 being completely confident

How many other medications do you regularly take with warfarin?: *

9 or more

6 - 8

3 - 5

1 - 2

only warfarin

I worry about my INR levels: *

From 1 being not at all worried, to 10 completely worried

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