Postpartum Hemorrhage Chief Complaint Intake Form
Please provide concise information regarding the postpartum hemorrhage concern to help us understand and address the issue promptly.
Patient's Full Name
*
First Name
Last Name
Patient Age
*
Date and Time of Bleeding Onset
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Estimated Amount of Blood Loss (in mL)
*
Description of Bleeding (color, clots, rate, etc.)
*
Associated Symptoms (select all that apply)
*
Dizziness
Fainting
Palpitations
Shortness of breath
Abdominal pain
None of the above
Other
Type of Delivery
*
Vaginal
Cesarean section
Assisted (forceps/vacuum)
Other
Time Since Delivery (in hours)
*
Any Interventions Already Taken?
*
Uterine massage
Medications given
IV fluids started
Transferred to higher care
None
Other
Contact Number for Follow-Up
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: