Post-Surgery Recovery Checklist
Track your recovery progress and ensure all post-surgery care steps are followed.
Patient Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Surgery
*
Current Symptoms (Select all that apply)
*
Fever
Increased pain at surgical site
Redness or swelling
Unusual discharge from wound
Difficulty breathing
Nausea or vomiting
None of the above
Other
Pain Level (1 = Minimal, 10 = Severe)
*
Minimal
1
2
3
4
5
6
7
8
9
Severe
10
1 is Minimal, 10 is Severe
Medication Checklist
Rows
Taken as prescribed
Missed dose(s)
Pain medication
1
2
Antibiotic
3
4
Other prescribed medication
5
6
Wound Care Status
*
Clean and dry
Needs attention
Unsure
Mobility/Activity Level
*
Fully mobile
Mobile with assistance
Mostly bedridden
Dietary Notes (e.g., eating well, any restrictions, loss of appetite)
Next Follow-up Appointment Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments or Concerns
Signature of Patient or Caregiver
Submit Checklist
Submit Checklist
Should be Empty: