Post-Hysterectomy Discharge Symptom Tracker Form
Track your recovery symptoms after hysterectomy discharge. Please complete this form daily to help monitor your progress.
Date of Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How do you feel overall today?
*
Excellent
Good
Fair
Poor
Pain Level (0 = No pain, 10 = Worst pain)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Have you experienced a fever (Temperature above 100.4°F / 38°C)?
*
No
Yes
Wound Appearance
*
Normal (clean, dry, no redness or swelling)
Mild Redness or Swelling
Discharge or Odor
Other
Are you experiencing any vaginal bleeding?
*
None
Light spotting
Moderate bleeding
Heavy bleeding
Any urinary symptoms (burning, frequency, urgency)?
None
Burning
Frequency
Urgency
Any bowel symptoms (constipation, diarrhea, difficulty)?
None
Constipation
Diarrhea
Difficulty passing stool
Are you able to move around comfortably?
*
Yes, no difficulty
Some difficulty
Unable to move without assistance
Additional Comments or Concerns
Submit
Should be Empty: