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Post Natal Intake Form

To be reviewed by Dr. Lydia Brodie

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Question 1 of 17

When did you give birth?

Question 2 of 17

How many children do you have?

Question 3 of 17

Do you experience 1 or more of the following:

(Select all that apply)
A

Urinary Incontinence (peeing when you laugh, sneeze or jump)

B

Fecal incontinence (having a bowel movement, wiping clean but finding residue later).

C

Pelvic Pressure or a bulge in the vaginal area

D

Bulging in the midline of the abdomen (diastasis recti)

E

Pain with sex or tampon insertion

F

Other ( please explain in detail in the next box)

G

None of the above

Question 4 of 17

If you answered other to the previous question, please explain below.

Question 5 of 17

Do you experience low back pain?

A

No

B

Yes

Question 6 of 17

Do you experience pelvic pain?

A

No

B

Yes

Question 7 of 17

Were forceps or vacuum used?

Question 8 of 17

Is there anything you'd like to tell me about your current health, and/or your future goals? (ie I want to run a marathon, get back to crossfit, lift my baby without back pain etc.)

C-Section Birth

Please answer the following if you had a C-Section.

Question 10 of 17

If you had a C-Section, is your incision horizontal or vertical?

Question 11 of 17

If you have had a C-Section, how many C-Sections have you had?

Question 12 of 17

Is the area around you incision painful or numb?

Question 13 of 17

Does the area immediately around your incision feel like thick or dense tissue as compared to 3 inches above the incision?

Vaginal

Please answer the following if you had a vaginal birth.

Question 15 of 17

Did you have any tearing, and how much? (degree or number of stitches)

Question 16 of 17

Did you have an episiotomy?

(Select all that apply)
A

No

B

Yes

Question 17 of 17

Is the area around you incision painful or numb?

Confirm and Submit