Episiotomy Healing Assessment Form
Please complete this assessment to help evaluate your recovery progress following an episiotomy. Answer each question as accurately as possible based on your recent experiences.
Rate your current level of pain at the episiotomy site.
*
No pain
0
1
2
3
4
5
6
7
8
9
Severe pain
10
0 is No pain, 10 is Severe pain
How would you describe the appearance of the healing area?
*
Normal (no redness or swelling)
Mild redness/swelling
Significant redness/swelling
Discharge or unusual odor
Other
Have you noticed any bleeding from the episiotomy site?
*
No bleeding
Light spotting
Moderate bleeding
Heavy bleeding
How would you rate your ability to sit comfortably?
*
Very uncomfortable
0
1
2
3
4
5
6
7
8
9
Completely comfortable
10
0 is Very uncomfortable, 10 is Completely comfortable
Are you experiencing any difficulty with urination?
*
No difficulty
Mild discomfort
Burning sensation
Incontinence or leakage
How often are you able to move around without pain?
*
All the time
Most of the time
Sometimes
Rarely
Please indicate if you have experienced any of the following symptoms in the past week.
*
Fever or chills
Increased pain or tenderness
Pus or unusual discharge
Unpleasant odor
None of the above
How would you rate your overall mood and emotional well-being?
*
Very low
0
1
2
3
4
5
6
7
8
9
Excellent
10
0 is Very low, 10 is Excellent
How would you describe your bowel movements since the procedure?
*
Normal
Occasional discomfort
Constipation
Painful or difficult
Overall, how satisfied are you with your recovery so far?
*
1
2
3
4
5
Submit Assessment
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