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

    (If it is more than 6 weeks 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 'yes' please describe:
  • 7. Have you been admitted to hospital since the birth of your baby? *
  • 7a) If 'yes' please describe:
  • 8. Have you had an operation since the birth of your baby? *
  • 8a) If 'yes' 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. Are you currently breast feeding your baby? *
  • 13. Have you ever breast fed 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 issues? *
  • 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.

  • Please answer the following question by marking one box.

  • 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 now 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? *
  • 21. Were limited in the kind of work or other activities *

  • 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 *
  • 23. Didn't do work or other activities as carefully as usual *

  • 24. During the past month,

  • how much did pain interfere with your normal work (including both outside the home and housework) *

  • 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? *
  • 26. Did you have a lot of energy? *
  • 27. Have you felt downhearted and blue? *

  • 28. During the last month,

    how much of the time has your PHYSICAL HEALTH OR EMOTIONAL PROBLEMS interfered with your social activities - like visiting with friends, relatives etc?
  • *
  • 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 answered 'other' to 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 tick the circle closest to your level of satisfaction
  • 31. 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
     
  • Your new mobile phone number
    (###)
    -
    ###
    -
    ####
     
    Please enter your mobile phone number if it has changed or we don't have it.
  • Your Email address
    Please enter your Email address if we don't already have it.
  • 32. Please provide the details of a contact person:
    If we lose contact with you, we would contact them and ask for your new details. You do not have to provide a contact if you don't want to.
  • My contact person is a:
  • Name of contact person
    First
    Last
     
  • Address of contact person
    Street Address
    Address Line 2
    City
    State / Province / Region
    Zip / Postal Code
    Country
     
  • Phone number of contact person
    (###)
    -
    ###
    -
    ####
     

  • Thank you very much for your participation. We will contact you for the 6 month follow-up.

    (Or you can complete the 6 month follow-up on our website www.popout.me)