Factor XII Registry
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  Information was provided by      
         
  Name      
  Name of Institution      
  Street address      
  Post/ZIP code, Town      
  Country      
  Phone      
  Fax      
  E-mail address    

  Demographic Data      
         
  Patient initials    
  Date of Birth    
  Gender    
  Ethnic Origion    
  Nationality    
  Place of Residence    
  Is the patient alive today    
  If no, please enter the date of death    
  Cause of death    
  Other family members with FXII deficiencys    

  Family Data      
         
  Parents    
  ABO Blood group      
              Father    
              Mother    
         
  Do parents suffer from a bleeding disorder    
  If yes, please specify    
       
       
         
  Do parents suffer from venous thromboembolism    
  If yes, please specify    
       
       
       
       
         
  Do parents suffer from a bleeding disorder    
  If yes, please specify    
       
       
         
  Do parents suffer from repeated infections    
  If yes, please specify    
       
       
       

  Patients Clinical Data      
         
  Age at diagnosis    
  Lowest FXII activity level    
  Method used for measuring FXII    
  Initial Manifistation      
  1- Bleeding    
       
       
       
       
       
       
       
       
       
       
       
       
         
  2- Thromboembolic events    
       
       
       
       
       
       
       
       
       
       
         
3- Repeated infections
       
       
       
       
       
       
       
       
         
  4- Spontanous abortion    
            Number of abortions    
  5- Angioedema    
            Provoking factor    

Laboratory data
  Bleeding time    
  aPTT    
  Prothrombin Time/ INR    
  Fibrinogen    
  vW:Rico    
  FXI    
  FIX    
  FVIII    
  Other    

Genotype Data      
         
  Are samples available for genetic testing    
  Has the parents been geneticaly tested for FXII    
  Has the patients mutations been analyzed?

   
       
  If known, describe the mutation    
       
         
       
         

Factor XII Registry        2015