HELP Questionnaire
HyperEmesis Level Prediction Questionnaire
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Current Weight
Last Week's Weight
Mark ONE box in EACH ROW that describes your symptoms over the last 24 hours unless specified otherswise.
0
1 (Mild)
2
3 (Moderate)
4
5 (Severe)
1. My Nausea level most of the time:
0 Times a Day
1-2 (Mild)
3-5
Mild/Mod
6-8 (Moderate)
9-12 (Mod/Severe)
13+
I average ___ vomiting epidoses/day:
0 Times a Day
1-2 (Mild)
3-5
Mild/Mod
6-8 (Moderate)
9-12 (Mod/Severe)
13+
I retch.dry heave ___ times a day:
Same
More Often due to IV fluids
Slightly less often, and normal color
Once every 8 hours or darker color
Less than
every 8 hours
or darker
Rarely; dark or bloody or foul smell
I am urinating/voiding
0
1 (Mild)
2
3 (Moderate)
4
5 (Severe)
Nausea/vomiting severity 1 hour after meds OR after food/drink if no meds:
0
1-2 (hours are
slightly less))
3-4 (can work
part time)
5-7
(can only do
a little work))
8-10
(can’t care for
family)
11+(can’t care for
myself)
Average number of hours I’m unable
to work adequately at my job and/or
at home due to being sick has been:
Normal
Tired but
mood is ok
Slightly
less than
normal
It’s tolerable
but difficult
Struggling:
moody,
emotional)
Poorly:
irritable
depressed
I have been coping with the nausea,
vomiting and retching
Same;
no
weight
loss
Total of
about 3
meals & 6+
cups fluid
Total of
about 2
meals &
some fluid
1 meal & few
cups fluid; or
only fluid or
only food
Very little, <1
meal/minimal
fluids; or
frequent IV
Nothing goes or
stays down,
or daily
IV/TPN/NG
Total amount I have been able to eat/
drink AND keep it down:
Medium water bottle/large cup = 2
cups/500mL.
Same;
no
weight
loss
Total of
about 3
meals & 6+
cups fluid
Total of
about 2
meals &
some fluid
1 meal & few
cups fluid; or
only fluid or
only food
Very little, <1
meal/minimal
fluids; or
frequent IV
Nothing goes or
stays down,
or daily
IV/TPN/NG
Total amount I have been able to eat/
drink AND keep it down:
Medium water bottle/large cup = 2
cups/500mL.
No
meds
Always
Nearly
always
Sometimes
Rarely
Never/IV/SQ
(SubQ pump)
My anti-nausea/vomiting meds stay down or are tolerated
Great
Better
About Same
Worse
Much Worse
So Much
Worse!!!
My symptoms compared to last week:
0%
1%
2%
3%
4%
5%
Weight loss over last 7 days: ___%
0
1
2
3
4
5+
Number of Medications for nasuea/vomiting:
Total Help Score
Severity
What your score means:
Your HELP Score gives us a picture of what you’re experiencing in relation to hyperemesis gravidarum which is severe morning sickness or nausea and vomiting or pregnancy. If you’d like support, our care team at Materna Health can contact you personally to talk through next steps and relief options.
Would you like our team to reach out to you with support, treatment and solution options?
Yes, please email me
Yes, please text me
Yes, please call me
No, don't reach out to me, just send me my score.
Submit
Materna Health use the Hyperemesis Gravidarum (HG) Severity Score (HELP Score) with permission, a validated tool developed by the HER Foundation to assess the severity of symptoms. The HELP Score is a standardized method that helps patients and providers track the impact of HG and guide treatment decisions. For more information and the HELP score validation study, visit www.hyperemesis.org.
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