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658 North Chase Street, Suite 301, Athens, GA 30601

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(706) 548-4272
APPOINTMENTS

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Postpartum Visit

Patient First Name

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Patient Last Name

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Email

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Date of Birth:

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Date of LMP:

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Group Label

Current Medications (include hormones, herbs, vitamins, nonprescription medicine)

Current Medications (include hormones, herbs, vitamins, nonprescription medicine)

Name and Dosage

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Name and Dosage

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Name and Dosage

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Name and Dosage

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Name and Dosage

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Name and Dosage

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Allergies (please include all drug allergies)

Allergies (please include all drug allergies)

Name

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Name

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Name

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Name

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Name

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Name

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What is your problem today:

What is your problem today:

Describe your problem. Location / Quality / Severity / Duration / Timing / Context / Modifying Factors / Assoc. Signs & Symptoms:

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Since Your Last Visit:

Since Your Last Visit:

Have you been diagnosed with a new medical problem since your last visit?

Yes

No

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Please Describe:

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Have you had any surgeries since your last visit?

Yes

No

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Please Describe:

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Have you been diagnosed with a new allergy?

Yes

No

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Please Describe:

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Do you have any new family history (parents, siblings, children)?

Yes

No

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Please Describe:

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Post-Partum Exam

Post-Partum Exam

Name:

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Date:

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Date of Delivery:

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Type of Delivery:

Vaginal

C-Section

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Physician that delivered your baby:

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Did you have an epidural?

Yes

No

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Did you have any complications?

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Name of baby:

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Sex of baby:

Male

Female

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Baby weight at Birth:

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Are you breast feeding or pumping milk?

Yes

No

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How long are you planning to breast feed/pump?

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Are you having any of the following problems?

Bleeding Problems

Yes

No

Please select an option.

GI Problems

Yes

No

Please select an option.

Urinary Complaints

Yes

No

Please select an option.

Pain Problems

Yes

No

Please select an option.

Mood or Depression Problems

Yes

No

Please select an option.

What birth control do you desire to use?

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Edinburgh Postnatal Depression Scale1 (EPDS)

Edinburgh Postnatal Depression Scale1 (EPDS)

As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

1. I have been able to laugh and see the funny side of things

As much as I always could

Not quite so much now

Definitely not so much now

Not at all

Please select an option.

2. I have looked forward with enjoyment to things

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all

Please select an option.

3. I have blamed myself unnecessarily when things went wrong

Yes, most of the time

Yes, some of the time

Not very often

No, never

Please select an option.

4. I have been anxious or worried for no good reason

No, not at all

Hardly ever

Yes, sometimes

Yes, very often

Please select an option.

5. I have felt scared or panicky for no very good reason

Yes, quite a lot

Yes, sometimes

No, not much

No, not at all

Please select an option.

6. Things have been getting on top of me

Yes, most of the time I haven’t been able to cope at all

Yes, sometimes I haven’t been coping as well as usual

No, most of the time I have coped quite well

No, I have been coping as well as ever

Please select an option.

7. I have been so unhappy that I have had difficulty sleeping

Yes, most of the time

Yes, sometimes

Not very often

No, not at all

Please select an option.

8. I have felt sad or miserable

Yes, most of the time

Yes, sometimes

Not very often

No, not at all

Please select an option.

9. I have been so unhappy that I have been crying

Yes, most of the time

Yes, quite often

Only occasionally

No, never

Please select an option.

10. The thought of harming myself has occurred to me

Yes, quite often

Sometimes

Hardly ever

Never

Please select an option.

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ATHENS OBGYN

658 North Chase Street
Suite 301 GA-30601

APPOINTMENTS (706) 548-4272

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