CHA2DS2-VASc CHA2DS2-VASc Your Name Age Gender ---FemaleMale Surgery Dr Date PLEASE ENSURE YOU ANSWER ALL QUESTIONS. Do you have a history of: Congestive Heart Failure ---NoYes Hypertension ---NoYes Stroke / TIA / Thromboembolism ---NoYes Vascular Disease ---NoYes Diabetes ---NoYes THANK YOU FOR COMPLETING THIS QUESTIONNAIRE. STAFF USE ONLY Participants NHS Number: Researchers Name: NHS Site Number: NHS Site Name: Postcode:
