Cesarean Delivery Recovery Checklist Form
Use this form to track your recovery after a cesarean delivery. Please answer each question to help monitor your progress and well-being.
Date of completing this recovery checklist
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate your current pain level?
*
No pain
0
1
2
3
4
5
6
7
8
9
Severe pain
10
0 is No pain, 10 is Severe pain
Have you experienced any of the following symptoms since your cesarean delivery?
*
Redness or swelling around incision
Fever above 100.4°F (38°C)
Unusual discharge or odor from incision
Heavy vaginal bleeding
Shortness of breath or chest pain
None of the above
Are you able to move around comfortably (e.g., walking, getting out of bed)?
*
Yes, without difficulty
With some discomfort
With significant difficulty
Unable to move without help
Are you keeping your incision area clean and dry?
*
Yes, always
Sometimes
No
How would you describe your current emotional state?
*
Positive and calm
Occasionally anxious or sad
Frequently anxious or sad
Overwhelmed or distressed
Are you able to sleep and rest adequately?
*
Yes, most nights
Sometimes
Rarely
Are you staying hydrated and eating regular meals?
*
Yes, consistently
Occasionally forget
Often forget
Do you have support at home to help with daily activities?
*
Yes, always
Sometimes
No
Do you have a scheduled follow-up appointment with your healthcare provider?
*
Yes
Not yet, but planning to schedule
No
Submit Checklist
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