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Postnatal Questionnaire

Please complete this questionnaire as best you can before your appointment.

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Personal Details

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?:

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:

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)

Medical History

Do you have a history of raised Blood Pressure?:

Smoking data:

Would you like help to quit smoking?:

Past pregnancies and births

Outcome - Live / still birth & Male / Female:

Addition Information

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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?:

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Postnatal Questionnaire

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Natural Delivery

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