LICEO DE CAGAYAN UNIVERSITY

Rodolfo N. Pelaez Blvd., Cagayan de Oro City

SCHOOL OF GRADUATE STUDIES

POSTPARTUM QUESTIONNAIRE

PART I. PATIENT PROFILE

CASE NO: DATE OF ADMISSION:

SEX: AGE:

DATE OF BIRTH: CIVIL STATUS:

OCCUPATION: EDUCATIONAL LEVEL:

GRAVIDA: PARITY:

MODE OF DELIVERY:

WEIGH: HEIGHT: BMI:

ADMITTING DIAGNOSIS:

ATTENDING PHYSICIAN(INITIALS):

DISCHARGED DIAGNOSIS:
 LICEO DE CAGAYAN UNIVERSITY
Rodolfo N. Pelaez Blvd., Cagayan de Oro City
SCHOOL OF GRADUATE STUDIES

PART II. PATIENT RECORDS

VITAL SIGNS

DATE BP TEMPERATU PR RR 02 SAT TOTAL DATA LEGEND:

RE

RESULT

SCORE

B-BREAST Appearance:

Tenderness:

Nipple Condition:

Engorgement:

U-UTERUS Fundal Height:

Firmness:

B-BOWEL

B-BLADDER
 LICEO DE CAGAYAN UNIVERSITY
Rodolfo N. Pelaez Blvd., Cagayan de Oro City
SCHOOL OF GRADUATE STUDIES

L-LOCHIA (BLEEDING SCALE 0-3)

0-NOBLEED 1-SCANTY 2-MODERATE 3-HEAVY

D1 D2 D3

E-EPISIOTOMY PAIN SCORE (NUMERICAL 0-10)

0 - NO PAIN 1-2 MILD PAIN 3-4 MODERATE PAIN 5-6 SEVERE
PAIN 7-8 VERY SEVERE PAIN 9-10 WORST PAIN IMAGINABLE

D1 D2 D3

H-HOMAN’S SIGN

E-EMOTIONAL Mood:
STATUS
Emotional Stability:

Crying Frequency:

Nurses notes/comments:

Postpartum Functional Assessment Questionnaire

Scale from 0 to 3
where 0 indicates the performance of activities without difficulty, 1 indicates the performance of
activities with minimal difficulty, 2 indicates the performance of activities of moderate difficulty, 3
indicates the inability to perform independently activities/necessary help

Functional abilities related to mobility SCORE

1. Able to turn to side

2. Able to get up

3. Able to sit

4. Able to walk
 LICEO DE CAGAYAN UNIVERSITY
Rodolfo N. Pelaez Blvd., Cagayan de Oro City
SCHOOL OF GRADUATE STUDIES

5. Able to do personal care

6. Able to take fluids

7. Able to take food

8. Able to sleep

9. Able to do oral care

10. Able to go to the toilet

11. Able to do child care

-Adopted from (Filipec et al., 2023)