Post-natal Questionnaire

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Day
Month
Year
3
Phone number
4
Email
example@example.com
5
Date of delivery
Date
Day
Month
Year
6
How many weeks pregnant were you at delivery?
7
How did you deliver?
Vaginal delivery
Vaginal delivery with episiotomy
Vaginal delivery with Ventouse
Vaginal delivery with Forceps
Emergency Caesarian section
Planned Caesarian section
Other
8
How was the birth?
9
How is your healing?
10
Describe any problems with incontinence of urine, if any?
11
Describe any problems with incontinence of faeces, if any?
12
Please read these leaflets about pelvic floor exercises:

Patient Info

NCT
13
How are you feeding your baby?
Breastfeeding / expressed breastmilk
Mixed breastfeeding and formula feeding
Formula feeding
Other
14
Are you having any problems with feeding your baby?
15
Are you having any abnormal vaginal bleeding or discharge?
16
How are things at home?
17
Who is at home with you?
18
How is your partner coping with parenthood?
19
Are you experiencing any domestic abuse? This includes verbal, emotional, financial, physical and sexual abuse. If so, please describe:
20
What is your smoking status?
Never smoked tobacco
Ex-smoker
Cigarette smoker
Vaping / e-cigarettes
Cannabis smoker
Other
21
Is motherhood what you thought it would be?Please explain.
22
In the past month, have you felt little interest or pleasure in doing things?
Yes - I have felt little interest and pleasure
No - I have had interest and pleasure in things
23
In the past month, have you often felt down, depressed or hopeless?
Yes
No
24
In the past two weeks, how often have you been bothered by being unable to stop worrying
not at all
several days
more than half the days
every day / nearly every day
25
In the past two weeks, how often have you been bothered by feeling nervous, anxious or on edge
not at all
several days
more than half the days
every day / nearly every day
26
Please read the following information about contraception:

Patient Info

NHS website
27
What is your current contraceptive method?
28
What is your plan for future pregnancies?
29
Would you be interested in long-acting contraceptive methods (see info in links above)
Yes
No
Not sure
30
What contraception would you be interested in?
31
Are you up to date with your cervical screening (smear) tests?If your cervical screening test was due during pregnancy, please wait 3 months after delivery before booking your test.
Yes
No
Don't know
32
Did you have gestational diabetes?
Yes
No
Don't know
33
Is there anything else you would like to discuss with the doctor at your postnatal appointment?
Should be Empty: