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questionnaire

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

Secured
1

Name of the patient .

2

Patient file number

Use digits only
3

age of the patient

Use digits only
4

gender of the patient

Select one or more answers
5

medical history of patient

6

name of anticoagulant

Select one or more answers
7

dosage of the drug

Use digits only
8

duration of the anticoagulant

Use digits only
9

indication for anticoagulant use

10

type of gib

Select one or more answers
11

patient initial vital sign parameter at the time of admission

12

is the patient at the time of presentation was shocked

Select one or more answers
13

initial hemoglobin

Use digits only
14

Glasgow-Blatchford Bleeding Score

Use digits only
15

does patient required admission to icu

Select one answer
16

how many unit of prbc patient received

Use digits only
17

how many unit of platelet received

Use digits only
18

how many unit of FFP received

Use digits only
19

therapy that patient received

20

endoscopy finding if done .

21

how many days patient stay in hospital

Use digits only
22

patient outcome