April 19, 2007
1
Pediatric Bleeding Questionnaire (PBQ)
Subject data
Date
Child’s Name
Parent’s Name
Address
Email
Phone Number
Gender
Male 
Age
Female 
DOB (dd/mm/yy)
Ethnic Background of:
Father
Mother
Presenting complaint of bleeding or bruising today?
Yes 
Ever been diagnosed with a bleeding disorder?
Yes 
No 
Diagnosis:
No 
 # of 1 degree family members studied 
degree family members  Notes:
Total # of 1st degree family members
# of diagnosed 1st
ABO Blood Group
A  B  AB  O 
Present questionnaire completed by
Menarche
st
N/A 
Rh -  Rh + 
Father 
Yes 
Mother 
Subject 
Age of menarche:
No 
Are you currently taking oral contraceptive pills? Yes  Brand Name:
No 
Specify any herbals and/or medications that you have taken in the past 30 days:
Name
Dose
Route
Frequency
Duration
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Past Medical History
Chief Complaint
Temperature (day of blood work)
April 19, 2007
2
Pediatric Bleeding Questionnaire (PBQ)
Bleeding symptoms
No 
Epistaxis
If Yes,
Trivial 
Significant 
AVERAGE PRESENTATION
Age of maximum severity
 0 - 4 years
 4 - 8 years
 8 - 12 years
 12 - 16 years
 16 - 20 years
Number episodes/year
<1
1-5
 6 - 12
 > 12
Duration of average single
episode
 < 1 minute
 1-10 minutes
 > 10 minutes
Spontaneous?
Yes 
No 
Both nostrils?
Yes 
No 
After drug ingestion
(e.g.aspirin)
Yes 
No 
Seasonal correlation
Yes 
No 
Specify:
 spontaneous
 after compression
 by medical intervention
Cessation
REPORT TREATMENT OF THE MOST SEVERE EPISODE
Required medical attention?
If yes, please specify:
Consultation only
Packing
Cauterization
Antifibrinolytics
Desmopressin
Replacement therapy
Blood transfusion
Notes
Yes 







# of times
# of times
# of times
# of times
# of times
# of times
No 
April 19, 2007
3
Pediatric Bleeding Questionnaire (PBQ)
Cutaneous symptoms
No 
If Yes,
Trivial 
Significant 
AVERAGE PRESENTATION
Type
 Petechiae
 Bruises
 Hematomas
Location of lesions (if any)
 Exposed sites
 Unexposed sites
 Both
Size of average
 < 1 cm
 1 – 5 cm
 > 5 cm
Minimal or no trauma
Yes 
No 
REPORT TREATMENT OF THE MOST SEVERE EPISODE
Yes 
Required medical attention?
No 
If yes, please specify:

Consultation only
Notes
Bleeding from minor
wounds
No 
If Yes,
Trivial 
Significant 
AVERAGE PRESENTATION
Number episodes/year
<1
1-5
 6 - 12
 > 12
Duration of average single
episode
 < 5 mins.
 > 5 mins.
REPORT TREATMENT OF THE MOST SEVERE EPISODE
Required medical attention?
Yes 
If yes, please specify:
Consultation or Steri-strips
Surgical hemostasis
Antifibrinolytics
Desmopressin
Replacement therapy
Blood transfusion






Notes
# of times
# of times
# of times
# of times
# of times
# of times
No 
April 19, 2007
4
Pediatric Bleeding Questionnaire (PBQ)
Oral cavity bleeding
No 
If Yes,
Trivial 
Significant 
AVERAGE PRESENTATION
 Tooth eruption/loss
 Gums, spontaneous
 Gums, after brushing
 Prolonged bleeding after
Type of bleeding
bites to lip & tongue
 Hemorrhagic bullae
REPORT TREATMENT OF THE MOST SEVERE EPISODE
Required medical attention?
Yes 
If yes, please specify:
Consultation only
Surgical hemostasis
Antifibrinolytics
Desmopressin
Replacement therapy
Blood transfusion






No 
# of times
# of times
# of times
# of times
# of times
Notes
Tooth extraction
No 
If Yes,
Trivial 
Total # of teeth extracted

# of teeth extracted
followed by bleeding
Significant 

MOST SEVERE OCCURRENCE
Age at extraction
Prophylaxis before extraction?
Bleeding after extraction?
Actions taken to control
bleeding
Notes

Type of extraction
 Deciduous
 Permanent
 None
 Antifibrinolytics
 Desmopressin
 Replacement therapy
Yes 
 None
 Consultation only
 Resuturing
 Packing
 Antifibrinolytics
 Desmopressin
 Replacement therapy
 Blood transfusion
No 
April 19, 2007
5
Pediatric Bleeding Questionnaire (PBQ)
Gastrointestinal bleeding
No 
Yes 
AVERAGE PRESENTATION

# of episodes
Type of bleeding
 Hematemesis
 Melena
 Hematochezia
Presence of associated
GI disease
Yes 
 Gastritis/ulcer
No 
 Colitis
 Mallory-Weiss tear
 Vascular malformations
 Other
REPORT TREATMENT OF THE MOST SEVERE EPISODE
Required medical attention?
Yes 
If yes, please specify:
Consultation only
Surgical hemostasis
Antifibrinolytics
Desmopressin
Replacement therapy
Blood transfusion






Notes
# of times
# of times
# of times
# of times
# of times
No 
April 19, 2007
6
Pediatric Bleeding Questionnaire (PBQ)
Surgery
No 
If Yes,
Total # of surgeries

# of surgeries followed
by bleeding
Specify
Trivial 
Significant 

MOST SEVERE OCCURRENCE
Age at surgery
Prophylaxis before surgery?
Bleeding after surgery?
Actions taken to control
bleeding
Notes

Type of surgery
Specify
 None
 Antifibrinolytics
 Desmopressin
 Replacement therapy
Yes 
 None
 Consultation only
 Resuturing/surgical
 Antifibrinolytics
 Desmopressin
 Replacement therapy
 Blood transfusion
No 
April 19, 2007
7
Pediatric Bleeding Questionnaire (PBQ)
Menorrhagia
N/A 
Duration of average
menstruation (days)
How often do you change your
pads/tampons
No 
Yes 

Duration of heavy
(days)

on heaviest days
on average days
_______ hours
_______ hours
What type of feminine product do you use? (i.e. panty liner, super absorbency tampon etc.)
Comments
MOST SEVERE PRESENTATION
Age of maximum severity
 8-12
 13-16
 17-20

Required medical attention?
If yes, please specify:
Consultation only
Pill use
Antifibrinolytics
Dilatation & curettage
Iron therapy
Desmopressin
Replacement therapy
Blood transfusion
Hysterectomy
Notes
>20 yrs
Yes 









# of times
# of times
No 
April 19, 2007
8
Pediatric Bleeding Questionnaire (PBQ)
Post-partum hemorrhage
N/A 
Total # of deliveries
No 
If Yes,
Trivial 

# of deliveries followed
by bleeding
Significant 

MOST SEVERE OCCURRENCE
Age at delivery

Mode of delivery
 spontaneous
 assisted
 c-section
Prophylaxis before delivery
 None
 Antifibrinolytics
 Desmopressin
 Replacement therapy
Bleeding after delivery?
Yes 
Actions taken to control
bleeding
 None
 Consultation only
 Resuturing/surgical
 Antifibrinolytics
 Desmopressin
 Replacement therapy
 Blood transfusion
 Hysterectomy
Notes
No 
April 19, 2007
9
Pediatric Bleeding Questionnaire (PBQ)
No 
Muscle hematomas
Yes 

Total #
MOST SEVERE PRESENTATION
Please specify type & location
Post-trauma?
Prophylaxis?
Required medical attention?
Yes 
 None
 Antifibrinolytics
 Desmopressin
 Replacement therapy
Yes 
If yes, please specify:
Surgical intervention

Desmopressin

Replacement therapy

Blood transfusion

Notes
No 
No 
April 19, 2007
10
Pediatric Bleeding Questionnaire (PBQ)
No 
Hemarthrosis
Yes 

Total #
MOST SEVERE PRESENTATION
Please specify type & location
Yes 
Post-trauma?
No 
 None
 Antifibrinolytics
 Desmopressin
 Replacement therapy
Prophylaxis?
Yes 
Required medical attention?
No 
If yes, please specify:
Surgical intervention

Desmopressin

Replacement therapy

Blood transfusion

Notes
CNS bleeding
No 
Yes 

Intracerebral, any
intervention
If yes, type of bleeding
Subdural, any intervention

April 19, 2007
11
Pediatric Bleeding Questionnaire (PBQ)
No 
Yes 
Umbilical stump

Cephalohematoma

Bleeding at circumcision

Venipuncture bleeding


Hematuria,
macroscopic

Other bleeding
If yes, type of bleeding
Male, not circumcised 
Male, circumcised 
Female 
Suction Bleeding
MOST SEVERE PRESENTATION
Please specify type
Required medical attention?
If yes, please specify:
Consultation only
Iron therapy
Surgical hemostasis
Antifibrinolytics
Desmopressin
Replacement therapy
Blood transfusion
Notes
Yes 







# of times
# of times
# of times
# of times
# of times
# of times
No 
April 19, 2007
12
Pediatric Bleeding Questionnaire (PBQ)
Other bleeding continued
MOST SEVERE PRESENTATION
Please specify type
Required medical attention?
If yes, please specify:
Consultation only
Iron therapy
Surgical hemostasis
Antifibrinolytics
Desmopressin
Replacement therapy
Blood transfusion
Yes 







No 
# of times
# of times
# of times
# of times
# of times
# of times
Notes
MOST SEVERE PRESENTATION
Please specify type
Required medical attention?
If yes, please specify:
Consultation only
Iron therapy
Surgical hemostasis
Antifibrinolytics
Desmopressin
Replacement therapy
Blood transfusion
Notes
Yes 







# of times
# of times
# of times
# of times
# of times
# of times
No 
April 19, 2007
13
Pediatric Bleeding Questionnaire (PBQ)
Table 1
Score
-1
0
1
No or trivial (≤5 per
year)
No or trivial (≤1cm)
>5 per year OR >10
minutes duration
>1cm AND no trauma
Consultation only
-
No or trivial (≤5 per
year)
No
>5 per year OR >5
minutes duration
Reported at least once
Consultation only or Steristrips
Consultation only
Gastrointestinal
tract
-
No
Identified cause
Consultation or spontaneous
Tooth extraction
No bleeding in at least
2 extractions
Reported, no
consultation
Consultation only
Surgery
No bleeding in at least
2 surgeries
-
None done or no
bleeding in 1
extraction
None done or no
bleeding in 1
No
Reported, no
consultation
Reported or consultation
only
Consultation only
No bleeding in at least
2 deliveries
-
No deliveries or no
bleeding in 1 delivery
Never
Reported or consultation
only
Post-trauma, no therapy
D&C, iron therapy or
antifibrinolytics
Spontaneous, no therapy
Spontaneous, no therapy
Symptom
Epistaxis
-
Cutaneous
-
Minor wounds
-
Oral cavity
Menorrhagia
Post-partum
Muscle hematoma
Hemarthrosis
-
Never
Post-trauma, no therapy
Central nervous
system
Other *
-
Never
-
-
No
Reported
2
3
Consultation only
Antifibrinolytics or
contraceptive pill use
Consultation only
4
Packing, cauterization or
antifibrinolytics
-
Blood transfusion, replacement
therapy or desmopressin
-
Surgical hemostasis or
antifibrinolytics
Surgical hemostasis or
antifibrinolytics
Surgical hemostasis,
antifibrinolytics, blood
transfusion, replacement therapy
or desmopressin
Resuturing, repacking or
antifibrinolytics
Blood transfusion, replacement
therapy or desmopressin
Blood transfusion, replacement
therapy or desmopressin
-
Surgical hemostasis or
antifibrinolytics
D&C or iron therapy
Blood transfusion, replacement
therapy or desmopressin
Blood transfusion, replacement
therapy, desmopressin or
hysterectomy
-
Blood transfusion, replacement
therapy or desmopressin
Spontaneous or traumatic,
requiring replacement therapy or
desmopressin
Spontaneous or traumatic,
requiring replacement therapy or
desmopressin
Subdural, any intervention
Surgical hemostasis,
antifibrinolytics or iron therapy
Blood transfusion, replacement
therapy or desmopressin
Spontaneous or traumatic,
requiring surgical intervention
or blood transfusion
Spontaneous or traumatic,
requiring surgical intervention
or blood transfusion
Intracerebral, any intervention
Blood transfusion, replacement
therapy or desmopressin
Table 1 shows the scoring key for the Pediatric Bleeding Questionnaire. In the last
row, the symptoms included in the “Other” category are: umbilical stump bleeding,
cephalohematoma, post-circumcision bleeding, post-venipuncture bleeding, and
macroscopic hematuria.