Post-Surgical Care Checklist Form
Please complete the following checklist to ensure proper post-surgical care.
Patient Full Name
First Name
Last Name
Date of Surgery
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Checklist Completion
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you experiencing any pain?
Yes
No
If yes, please rate your pain level
1
1
2
3
4
Best
5
1 is , 5 is Best
Are you taking prescribed medications as directed?
Yes
No
Have you noticed any signs of infection (redness, swelling, discharge)?
Yes
No
Are you following the recommended wound care instructions?
Yes
No
Have you experienced any unusual symptoms or complications?
Additional notes or comments
Submit
Should be Empty: