IC Radiology CVST Following AstraZen Vacc 2021 Online Forms Current User: Not Logged In
Bedfordshire Hospitals
NHS Foundation Trust

Identification of Cerebral Venous Sinus Thrombosis Following
AstraZeneca Vaccine and Subsequent CT and MRI Venogram
Demographics and Patient Characteristics
3 Gender
Male
Female
1 Hospital Number
2 Age
4
Comorbidities
Hypertension
Heart Failure
Other chronic
heart disease
Dementia
Cerebrovascular Disease
Chronic neurological
disease other than
stroke/dementia
Asthma
COPD
Other chronic
Respiratory Disease
Type 1 Diabetes
Type 2 Diabetes
CKD
Haematological
Malignancy
Non-haematological
Malignancy
Liver Disease
Organ Transplant
Rheumatoid arthritis/
lupus/psoriasis
Other Disease
Please specify if Other Disease was selected
5
Number of Co-morbidities
1
2
3
4
5 or more
7 Risk factors for thrombosis
Yes
No
6 Oral contraception
8 If risk factor for thrombosis then specify which
Presentation
9
Symptoms:
Headache
Visual disturbance
Nausea, vomiting
Cranial nerve palsy
Aphasia
Aphasia
Hemisensory loss and
/or hemiparesis
Seizures
Disturbance in
mental status
Meningism
Other
Please specify if Other Disease was selected
Click 'Next Page' after completing this page from the left navigation menu