SECTION 1: Participant & Birth Information

Participant ID#

Date of birth of your child

Name of child

Sex of child

MaleFemaleOther

Weight of child

Length of child

Vaginal or cesarean delivery

VaginalCesarean

Duration of labor

Infant health (select all that apply)

Healthy, no complicationsLow birth weight (less than 5.5 lbs)Required NICU careMiscarriage or stillbirthOther

Infant health – Other (please specify)

Birth setting

Hospital birthHome birthBirth center

Did you have any medical complications with the birth of your child?

Drugs taken during labor (e.g. pitocin, morphine, epidural)

Drugs taken post labor (e.g. ibuprofen)

If birthed at a hospital or birth center, did you go home the same day?

YesNo

Is your partner living in the home with you?

YesNo

Beyond support from your child’s father, do you have any outside help?
If yes, have you returned to work or plan to return to work and when?

SECTION 2: Breastfeeding & Postpartum Care

Breastfeeding status

Currently breastfeedingPlanning to breastfeedNot breastfeeding

If you are breastfeeding, have there been any complications?

If breastfeeding, how long do you plan to breastfeed?

Did you use any lactation comfort measures (salve, cabbage leaves, etc.)?

Are you practicing any special postpartum family traditions?

Have any family postpartum healing traditions been forced upon you?

Was any care offered to you from the hospital staff?

Have you used any teas or herbs suggested in the program? If so, which?

Have you tried any warming treatments?

YesNo

Did you adhere to the postpartum diet protocol for the first 3 weeks?
Any favorites or foods you didn’t like?

Did you bind yourself?

YesNo

Did you try the fear release exercise during pregnancy?

YesNo

Did you do a birth de-briefing journal exercise yet?

YesNo

Have you used music to help you relax or bond with your baby?

Do you and your family feel financially secure, or do you have concerns?

Have you been able to set up a daily routine with you and your baby?

YesNo

Do you feel comfortable caring for your baby? If not, what concerns do you have?

Have you needed to see your caregiver or doctor for any reason?

Have you been able to leave the house with ease yet?

YesNo

Have you had any social contact outside your immediate household?

YesNo

SECTION 3: Program Adherence

How often did you follow the postpartum healing protocol in the past week?

Daily (6–7 days)Most days (4–5 days)Some days (2–3 days)Rarely (0–1 day)Not at all

What got in the way? (Select all that apply)

Baby’s scheduleFatigue / low energyPain or physical limitsForgot / no timeDidn’t like the activityNothing — it went great!

Other barriers (if any)

Rate the program so far (1 = Not helpful, 5 = Very helpful)

12345

SECTION 4: Recovery Check-In (Likert Scale)

I feel physically recovered (energy, pain, mobility)

12345

My sleep quality has improved

12345

I feel confident caring for my baby

12345

I have support from family or friends

12345

SECTION 5: Edinburgh Postnatal Depression Scale (EPDS)

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

As much as I always could (0)Not quite so much now (1)Definitely not so much now (2)Not at all (3)

I have looked forward with enjoyment to things

As much as I ever did (0)Rather less than I used to (1)Definitely less than I used to (2)Hardly at all (3)

I have blamed myself unnecessarily when things went wrong

No, never (0)Not very often (1)Yes, some of the time (2)Yes, most of the time (3)

I have been anxious or worried for no good reason

No, not at all (0)Hardly ever (1)Yes, sometimes (2)Yes, very often (3)

I have felt scared or panicky for no good reason

No, not at all (0)No, not much (1)Yes, sometimes (2)Yes, quite a lot (3)

Things have been getting on top of me

No, I’ve been coping as well as ever (0)No, most of the time I’ve coped quite well (1)Yes, sometimes I haven’t been coping as well as usual (2)Yes, most of the time I haven’t been able to cope (3)

I have been so unhappy that I have had difficulty sleeping

No, not at all (0)Hardly ever (1)Yes, sometimes (2)Yes, most of the time (3)

I have felt sad or miserable

No, not at all (0)Hardly ever (1)Yes, quite often (2)Yes, most of the time (3)

I have been so unhappy that I have been crying

No, never (0)Only occasionally (1)Yes, quite often (2)Yes, most of the time (3)

The thought of harming myself has occurred to me

Never (0)Hardly ever (1)Sometimes (2)Quite often (3)

SECTION 6: Open Feedback

What’s working well in the program?

What should we change for the next 3 weeks?

Anything else on your mind? (optional)