Caprini Rsk Score – Venous Resource Center

Know your Risk for Blood Clots & Save Your Life

Your Total Score:

Only your doctor can determine if you are at risk for Deep Vein Thrombosis (DVT), a blood clot that forms in one of the deep veins of your legs.A review of your personal history and current health may determine if you are at risk for developing this condition. Please take a moment to complete this form for yourself (or complete it for a loved one). Then be sure to talk with your doctor about your risk for DVT and what you can do to help protect against it.

1. Please select your AGE *
2. Medical history (click each statement that applies) *
3. For women only (click each statement that applies)
4. Current medical conditions (click each statement that applies) *
5. Blood clot history (click each statement that applies) *
6. Mobility (click each statement that applies) *
7. Severe medical complications within the past month (click each statement that applies) *
8. Scheduled Surgery (click each statement that applies) *
9. Body Mass Index (BMI) (select one) *
10. Additional Risk Factors (click each statement that applies)
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