Postpartum Dermatitis Symptom Assessment Form
Please complete this form to help assess your postpartum dermatitis symptoms. Your responses will guide your care and support.
How many weeks postpartum are you?
*
Have you noticed any skin changes since delivery?
*
Yes
No
Which areas of your body are affected? (Select all that apply)
Face
Neck
Chest
Abdomen
Arms
Legs
Other
Symptom Severity Assessment
*
Rows
None
Mild
Moderate
Severe
Itching
1
2
3
4
Redness
5
6
7
8
Swelling
9
10
11
12
Dryness/Scaling
13
14
15
16
Pain/Tenderness
17
18
19
20
When did you first notice your symptoms?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have your symptoms changed over time?
Improved
Worsened
Stayed the same
How much do your symptoms interfere with your daily activities?
*
Not at all
1
2
3
4
Extremely
5
1 is Not at all, 5 is Extremely
Have you tried any treatments or remedies?
Yes
No
If yes, please specify what you have tried.
Is there anything else you would like to share about your symptoms?
Submit Assessment
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