Post Natal Check Up Appointment

Post Natal Screening Check up

Congratulations on the birth of your new baby. This form is designed with you in mind to identify any areas where we can offer support including Post Natal Mental Health, contraception and/or any birth issues. Please complete a form if you feel this applies to you and a member of our trained team will be in touch to give you advice if required.

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Name

First Last

Date of Birth

1. I have been able to laugh and see the funny side of things

Over the last 7 days...

2. I have looked forward with enjoyment to things

Over the last 7 days...

3. I have blamed myself unnecessarily when things went wrong

Over the last 7 days...

4. I have been anxious or worried for no good reason

Over the last 7 days...

5. I have felt scared or panicky for no very good reason

Over the last 7 days...

6. Things have been getting on top of me

Over the last 7 days...

N/A	Yes, most of the time I haven't been able to cope at all	Yes, sometimes I haven't been coping as well as usual	No, most of the time I've coped quite well	No, I have been coping as well as ever

7. I have been so unhappy that I have had difficulty sleeping

Over the last 7 days...

8. I have felt sad or miserable

Over the last 7 days...

9. I have been so unhappy that I have been crying

Over the last 7 days...

10. The thought of harming myself has occurred to me

Over the last 7 days...

Further information...

If you are concerned about you mental health and feel you need to speak to someone urgently, please contact the surgery on 0114 229 1686 opt 2, for an on the day telephone call.

Other

Contraception - Options

Following delivery, it is possible to get pregnant very quickly! Please select an option below so we can offer you advice and support regarding contraception.

I know which form of contraception I would like... (please specify below)

I am unsure and will look into it on sexwise (www.sexwise.org.uk) and get back to the surgery or attend SHS (Sexual Health Service)

I am unsure and would like to discuss in more detail with the nurse

Other

Your safety

Please advise the surgery if you are experiencing or experienced domestic violence. Even if you are unsure, if you have any concerns regarding your safety, please inform our team below.

Do you wish to speak with us regarding any other issues?

Perhaps you had a traumatic birth and require some support? Or you are not sure if your stitches are healing as they should? Anything you feel we can help with not addressed earlier in the questionnaire, please write further information below.