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As part of our research, we are looking for cases of DVT from all over the world. If you or someone you know has been diagnosed with DVT then please complete all sections below:

Information collected here will be kept strictly confidential.

Personal details:

Name:
  
Address:
  
 
City:
  
Post/zip code:
  
County/state:
  
Country:
  
Telephone:
  
E-Mail:
  
Age:
 
Height::
  
Do you smoke:
  
Are you overweight:
  
Were you pregnent:
  
Recent surgery:
  
History of DVT:
  

DVT Information

Duration of flight:
  
Airline:
  
Class:
  
Year of DVT:
  
 
Please state any chronic deseases (i.e. diabetes or heart problems)
 

Please state any medication you took prior to DVT, including HRT or Contraceptive Pill
 
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By clicking the submit button you accept that Aviation Health will store the details you have provided and use them for research and statistical analysis. Your personal details and your specific medical circumstances will not be shared with any third party without your explicit permission.

 
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