Bleeds & Hemorrhage Assessment Please enable JavaScript in your browser to complete this form.DateFirst Occurrence Date: Approximate Date You Developed a Problem with Your MemoryHave You Experienced Any of the Following:Join BleedsGastro Intestinal BleedsGenitourinary BleedsEasy Skin BruisesMuscle BruisingSkeletal DeformationHas Anyone in Your Family Had Any of the Following:Hemophilia AHemophilia Bvon Willebrand's DiseaseVitamin K DeficiencyPlatelet DisorderWarfarin ToxicityLiver FailureAnemiaDisorder of Bone MarrowBlood ClotsPulmonary EmbolismStrokeDeep Vein ThrombosisHeart ArrhythmiasHeart AttackIs Your Blood Pressure Normal?YesNoN/AA normal blood pressure is 120 over 80.Is Your Pulse/Heart Rhythm NormalYesNoN/AA normal blood pressure is 120 over 80.Have You Had:Varicose VeinsPsoriasisCyanosis (blue color)Sickle Cell DiseaseShortness of BreathPalpitationsFainting SpellsShortness of BreathDiabetesSubmit