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Postnatal Health Questionnaire Template

Are you a professional who works with postpartum women? If so, you know how important it is to assess their health and well-being. That’s why we have created the Postnatal Health Questionnaire Template to make it easier for you to gather important information about your clients.

This template contains questions that are designed to get a more holistic view of your clients’ health. Questions range from physical to mental health and lifestyle, enabling you to get a full picture of your clients’ postnatal health.

With this template, you can quickly and easily collect data from your clients, allowing you to provide them with the best possible care. The template also makes it easy to track changes in your clients’ health over the course of their postpartum period.

This template is the perfect way for you to assess your clients’ postnatal health and well-being in a comprehensive way. With it, you can provide your clients with the best possible care and ensure that their postpartum health is being monitored closely.

Postnatal Health Questionnaire Template

  1. Name
  2. Email
  3. Age
  4. Phone number
  5. Height
  6. Weight
  7. Number of Pregnancies
  8. Number and dates of delivery(ies)?
  9. Delivery method(s)
  10. What was the length of your labor (if known)?
  11. Did you have any tearing? If so what degree (if known)?
  12. Did you have any medical interventions (forceps, vacuum, episiotomy)?
  13. Did you have any complications during pregnancy?
  14. If yes, please explain.
  15. Please describe anything about your birth experiences you would like (if desired).
  16. What kind and how much exercise did you do prior to pregnancy?
  17. Did you exercise during your pregnancy? If yes, how did this differ to prior and how did it change throughout pregnancy?  
  18. Do you have or have you been checked for Diastasis Recti?
  19. Have you ever been to a Pelvic Floor Physical Therapist?
  20. Please check if you have or have ever had any of the following:
  21. If you are newly postpartum, have you been "cleared" for exercise by your practitioner?
  22. Do you experience any pain at this time?
  23. If yes, please describe.
  24. Please check any of the following symptoms you experience.
  25. How much water are you drinking per day on average?
  26. How much sleep do you get (on average) in a 24-hour period?
  27. Are you currently breastfeeding?
  28. If yes, have you had any unexpected changes in milk supply?
  29. Are you currently physically active? Please explain. (time/week, how long, what activities)
  30. What kind of movement/physical activity to you enjoy?
  31. Are there any activities that you would like to participate in and are not able to at this time? Please explain.
  32. What are you physical/health goals for the next 2-3 months?
  33. What are you goals for the next 6 months to a year?
  34. On a scale of 1-5, how ready and willing are you to make changes to move towards these goals? (1 - not ready/willing, 5 - fully dedicated)
  35. What, if any, are the barriers that may get in the way of your goals?
  36. How many days per week can you dedicate to structured movement?
  37. How much time in a day are you able to dedicate to structured movement?
  38. How much self care time do you get? What do you like to do during this time?
  39. Who is your support system?
  40. Are you currently working outside of parenting?
  41. If yes, what does your work entail?
  42. Do you consider you food intake to be adequate and overall nourishing?
  43. How are you feeling emotionally? Any postpartum depression/anxiety symptoms?
  44. What is your perceived stress level on a scale of 1-5, 5 being very stressful?
  45. What are 3 things you love about yourself/your body/your life?
  46. Please write anything else you would like me to know!
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