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  • If you are in the POPOUT Trial, please complete this form, about 6mths after the birth of your baby.

    (If it is more than 6 months after the birth of your baby, we would appreciate it if you could still complete this form)
  • 1. First letter of your first name *
    eg if your name is Mary Smith, type in 'M'
  • 2. First letter of your surname *
    eg if your name is Mary Smith, type in 'S'
  • 3. The hospital where my baby was born *
  • 4. The date my baby was born *
    DD
    /
    MM
    /
    YYYY
     
  • 5. Have you been well since discharge from hospital? *
  • 5a) If you answered 'no' to the last question, please describe:
  • 6. Have you gone to the doctor or hospital for problems with your health after your baby was born? *
  • 6a) If you answered 'yes' to the last question, please describe
  • 7. Have you been admitted to hospital since the birth of your baby? *
  • 7a) If you answered 'yes' to the last question, please describe
  • 8. Have you had an operation since the birth of your baby? *
  • 8a) If you answered 'yes' to the last question, please describe
  • 9. Since the birth of your baby, have you felt significantly depressed or down? *
  • 9a) If you have felt depressed or down, have you seen a doctor about this?
  • 10. Have you started anti-depressant medications since the birth of your baby? *
  • 11. Has your baby been well since discharge from hospital? *
  • 11a) If you answered 'no' to the last question, please describe:
  • 12. Have you ever breast fed your baby? *
  • 13. Are you currently breast feeding your baby? *
  • 14. How many weeks after the birth of the baby did you stop breast feeding? (answer if relevent)
  • 15. Have you taken your baby to the doctor or hospital for any health problems since birth? *
  • 15a) If yes, please describe
  • 16. Has your baby been admitted to hospital since birth? *
  • 16a) If yes, please describe
  • 16b) Has your baby had an operation? *
  • 16c) If yes, please describe

  • The next set of questions (17 - 28) ask for your views about your health.

    This information will help keep track of how you feel and how well you are able to do your usual activities. Please answer every question by marking one box. If you are unsure about how to answer, please give the best answer you can.
  • 17. In general, would you say your health is: *
    Excellent
    Very good
    Good
    Fair
    Poor
    If you are unsure about these questions, please give the best answer you can.

  • The following items are about activities you might do during a typical day.

    Does your health limit you in these activities? If so, how much? ...
  • 18. Moderate activities such as moving a table, pushing a vacuum cleaner, bowling or playing golf *
    Yes, limited a lot
    Yes, limited a little
    No, not limited at all
  • 19. Climbing several flights of stairs *
    Yes, limited a lot
    Yes, limited a little
    No, not limited at all

  • During the past month:

    Have you had any of the following problems with your work or other regular daily activities AS A RESULT OF YOUR PHYSICAL HEALTH? ...
  • 20. Accomplished less than you would like? *
    Yes
    No
  • 21. Were limited in the kind of work or other physical activities? *
    Yes
    No

  • During the past month :

    Have you had any of the following problems with your work or other regular daily activities AS A RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)? ...
  • 22. Accomplished less than you would like? *
    Yes
    No
  • 23. Didn't do work or other activities as carefully as usual? *
    Yes
    No

  • 24. During the past month,

  • how much did PAIN interfere with your normal work - both work outside the home and housework? *
    Not at all
    A little bit
    Moderately
    Quite a bit
    Extremely

  • These questions are about how you feel and how things have been with you DURING THE PAST MONTH. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time

  • during the past month,

  • 25. Have you felt calm and peaceful? *
    All of the time
    Most of the time
    A good bit of the time
    Some of the time
    A little of the time
    None of the time
  • 26. Did you have a lot of energy? *
    All of the time
    Most of the time
    A good bit of the time
    Some of the time
    A little of the time
    None of the time
  • 27. Have you felt downhearted and blue? *
    All of the time
    Most of the time
    A good bit of the time
    Some of the time
    A little of the time
    None of the time

  • 28. During the past month

    how much of the time has your PHYSICAL HEALTH OR EMOTIONAL PROBLEMS interfered with your social activities - like visiting with friends, relatives etc?
  • . *
    All of the time
    Most of the time
    Some of the time
    A little of the time
    None of the time
  • 29. In the past 24 hours have you experienced any pain? *
  • 29a) If yes, where? (tick as many as relevent)
    Head
    Back
    Deep inside abdomen
    Front/outside abdomen
    Bottom/genital area
    Other
  • 29b) If you selected 'other' for the last question, please describe
  • 30. Were you satisfied with your birth? *
    1 - Not at all satisfied
    2
    3
    4
    5
    6
    7
    8
    9
    10 - Extremely satisfied
  • Please let us know if your contact details have changed
    (complete only if your details have changed and you are happy for us to have your new contact details)
  • New Address
    Street Address
    Address Line 2
    City
    State / Province / Region
    Zip / Postal Code
    Country
     
    (complete only if your details have changed and you are happy for us to have your new contact details)
  • Your new mobile number
    (###)
    -
    ###
    -
    ####
     
  • Your new Email address

  • Thank you very much for your participation. We will contact you for the 1 year follow-up.

    (or you can complete the one year follow-up on our website at www.popout.me)