Postpartum Lochia Assessment Form
Evaluate postpartum bleeding and lochia status with this comprehensive assessment form.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Days Since Delivery
*
Current Lochia Amount
*
Scant
Light
Moderate
Heavy
Lochia Color
*
Rubra (Red)
Serosa (Pink/Brown)
Alba (Yellow/White)
Odor of Lochia
*
No odor
Faint/mild odor
Strong/unpleasant odor
Presence of Blood Clots
*
None
Small clots (<2.5cm)
Large clots (>2.5cm)
Associated Symptoms
*
Abdominal pain/cramping
Fever/chills
Foul-smelling discharge
Dizziness/weakness
None
Lochia Flow Pattern (compared to previous day)
*
Decreasing
Unchanged
Increasing
Patient Comfort with Bleeding
*
Very uncomfortable
1
2
3
4
Very comfortable
5
1 is Very uncomfortable, 5 is Very comfortable
Assessment Summary / Additional Notes
Is follow-up or referral indicated?
*
No
Yes, schedule follow-up
Yes, refer to provider
Submit Assessment
Should be Empty: