HHT Foundation International, Inc.

Epistaxis Journal
P.O. Box 329, Monkton, MD 21111
Tel: 410-357-9932 _________________________________
Fax: 410-357-0655 (name)

Calculate your Epistaxis Severity Score at

www.curehht.org
Diary of HHT Treatments

Date Treatment Performed By Result Month / Year ________ Month / Year ________
Hematocrit: _________ Hematocrit: _________
Hemoglobin: ________ Hemoglobin: ________
ESS: ______________ ESS: ______________

Month / Year ________ Month / Year ________

Hematocrit: _________ Hematocrit: _________
Hemoglobin: ________ Hemoglobin: ________
ESS: ______________ ESS: ______________

Month / Year ________ Month / Year ________

Hematocrit: _________ Hematocrit: _________
Hemoglobin: ________ Hemoglobin: ________
ESS: ______________ ESS: ______________
Monthly Results

Month / Year ________ Month / Year ________

Hematocrit: _________ Hematocrit: _________
Hemoglobin: ________ Hemoglobin: ________ Name ___________________________________
ESS: ______________ ESS: ______________
Date of Birth ______________________________

Month / Year ________ Month / Year ________ Gender __________________________________

Hematocrit: _________ Hematocrit: _________
Hemoglobin: ________ Hemoglobin: ________ Primary Care Physician Name / Address / Phone
ESS: ______________ ESS: ______________ ________________________________________
________________________________________

Month / Year ________ ________________________________________

Month / Year ________
Hematocrit: _________ Hematocrit: _________ ________________________________________
Hemoglobin: ________ Hemoglobin: ________
ESS: ______________ ESS: ______________
Clinical Diagnosis of HHT Baseline Medical Information

Date:
Curacao Criteria for HHT
Epistaxis Spontaneous
Current Hematocrit:
Telangiectasia Multiple
Visceral Lesion GI, Spinal, Cerebral, Pulmonary, Current Hemoglobin:
Liver Pulmonary AVMs:
Family History First Degree Relative
Cerebral AVMs:

HHT Diagnosis is: GI Telangiectasia:
DEFINITE 3 Criteria Present Nasal Telangiectasia:
PROBABLE 2 Criteria Present Genetic Testing Result:
UNLIKELY <2 Criteria
Epistaxis Severity Score (ESS):