Postnatal Questionnaire

 
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Personal Details
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Post-natal Details
Delivery Method: *
Have you had a period since your delivery?:
Did you have any episiotomy, tears, or stitches?:
Has it healed?:
Has your C-section scar healed as expected?:
Do you have any problems with hemorrhoids or anal fissures?:
Do you have any trouble controlling your bladder?:
Do you have any prolapse symptoms?:
Are you doing pelvic floor exercises?:
Is there any need for a doctor to examine you following your recent delivery?:
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Postnatal Depression Scale

We would like to know how you are feeling. Please choose the answers that come closest to how you have felt in the PAST 7 DAYS not just how you feel today.

I have been able to laugh and see the funny side of things:
I have looked forward with enjoyment to things:
I have blamed myself unnecessarily when things went wrong:
I have been anxious or worried for no good reason:
I have felt scared or panicky for no very good reason:
Things have been getting on top of me:
I have been so unhappy that I have had difficulty sleeping:
I have felt sad or miserable:
I have been so unhappy that I have been crying:
The thought of harming myself has occurred to me:
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Family Planning

C-section

Following caesarean section it is advised to avoid conception for at least 12 months for medical reasons.

Natural Delivery

Following normal delivery, conception is a social choice and there is usually no medical restriction unless there are other medical problems to consider.

What contraception methods are you using?:
Do you need a advice or a prescription for contraception?:
Any history of migraine?:
Any personal history of pulmonary embolism or deep-vein thrombosis (Clots in the lung or leg needing anticoagulation treatment)?:
Any breast disease?:
Any family history of breast cancer?:
Any personal or family history of cardiovascular disease under 45 years old?:
(heart attack, stroke, gangrene)
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Medical History
Do you have a history of raised Blood Pressure?:
Smoking data:
Would you like help to quit smoking?:
Addition Information
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Past pregnancies and births
Outcome - Live / still birth & Male / Female:
Outcome - Live / still birth & Male / Female:
Outcome - Live / still birth & Male / Female:
Outcome - Live / still birth & Male / Female:
Outcome - Live / still birth & Male / Female:
Outcome - Live / still birth & Male / Female:
Outcome - Live / still birth & Male / Female:
Outcome - Live / still birth & Male / Female:
Outcome - Live / still birth & Male / Female:
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Baby's Details
Feeding details
Feeding method:
Baby's development
Does your baby watch your face and follow with his/her eyes?:
Does your baby turn towards the light?:
Does your baby smile at you?:
Do you think your baby can hear you?:
Is your baby startled by loud noises?:
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Privacy Consent

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