Postnatal Review

Last Updated: 14/08/2020

Personal Details

First name *

Surname *

Date of birth *

Pregnancy and Delivery

Did you experience any health concerns during pregnancy? *

Yes No

What was your delivery date? *

What type of delivery did you have? *

Normal vaginal delivery

Vaginal delivery with forceps

Vaginal delivery with ventouse (suction)

Planned Caesarean section

Emergency Caesarean section

Other

Health

Do you have any concerns at the moment? *

Please enter your most recent blood pressure reading/s *

If you had a Caesarean birth, episiotomy or tear - are your stitches healing? Do you have any discomfort?

Have your periods returned since your delivery? *

Yes

Other

Have you experienced any vaginal discharge since giving birth? This can include unusual discharge, thrush symptoms, blood clots etc. *

Are you bowel and bladder functioning normally? *

Are you currently breastfeeding? *

Yes

Yes and supplementing with bottles

Would you like more information or support regarding breast feeding? *

Yes No

Social

Who are your main sources of support? *

How are things at home? *

Would you like some information about post-natal support groups? *

Yes No

Mental Health

Is motherhood what you thought it would be? *

Since giving birth, have you felt little interest or pleasure in doing things? *

Yes No

Since giving birth, have you often felt down, depressed or hopeless? *

Yes No

Sexual Intercourse

Are you sexual active? *

Yes No

If yes - do you need contraception?

Is sexual intercourse painful?

Yes No

Questions or Concerns

Any questions or concerns?

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Postnatal Review

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