Wellspring Health Access - Follow-Up Assessment

Name

First NameLast Name
Date of Birth
Phone Number
Please enter a valid phone number.
May we leave a message?

YesNo
Email
example@example.com
Preferred Method of Contact

PhoneEmail
Follow-Up Evaluation:
Date of procedure

MonthDayYear
Date
Tell us about your recovery:
What are the results of your at-home pregnancy test:

Not pregnantPregnant
How are you feeling now?
Do you have any concerns?
Tell us about your bleeding:
Number of days bleeding?
Color of Bleeding:
If you chose "Other", please explain:
Additional Questions:
Do you have any other vaginal discharge?

YesNo
Do you still have nausea?

YesNo
Do you still have breast tenderness?

YesNo
Did you start any hormonal birth control?

YesNo
*** If you would like a prescription for birth control, please call us. We would be happy to take care of that for you. ***
When was your last Well Woman Exam/Pap Smear test?
Can we help you with any Gynecological service or concerns?

YesNo
If yes, please explain:
Have you had sexual intercourse since your procedure?

YesNo
Would you like us to call you to answer any further questions you may have?

YesNo
Should be Empty:

Follow-Up Evaluation: