产康初诊评估表

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Postpartum Recovery Assessment Form / 产康初诊评估表

Basic Information / 基本信息

Email / 电邮: Name / 姓名: Age / 年龄: Occupation / 职业: Contact No / 联系号码: Address / 住址: Postnatal Period / 产后时间: Weight (kg) / 体重: Height (cm) / 身高: BMI / 身体质量指数:

Postpartum Overview / 影响因素

Labour Method / 分娩方式:

Normal Delivery / 自然产 Caesarean Section / 剖腹产 Foetal Suction / 胎吸 Forceps / 产钳 Others / 其他

Surgical Approach / 手术入路:

Longitudinal Incision / 纵向切口 Transverse Incision / 横向切口

Mother’s Prenatal Weight / 母亲产前体重: Mother’s Postpartum Weight / 母亲产后体重: Return of Menstruation / 月经恢复时间:

Conclusion / 结论

Remarks / 备注

Diastasis Recti Assessment / 腹直肌分离评估

Supraumbilical (cm) / 脐上分离: Umbilical (cm) / 脐中分离: Subumbilical (cm) / 脐下分离: Stretch Mark Area / 妊娠纹部位:

Right Upper Abdomen / 右上腹 Right Lower Abdomen / 右下腹 Right Lumbar / 右腰 Left Upper Abdomen / 左上腹 Left Lower Abdomen / 左下腹 Left Lumbar / 左腰

Stretch Mark Severity / 妊娠纹程度:

Mild / 轻 Moderate / 中 Severe / 重

Rib Cage Flare / 肋骨外翻评估

Costal Angle / 肋缘角:

≤ 90° / 小于等于90° ＞ 90° / 大于90°

Symphysis Pubis Evaluation / 耻骨联合评估

Symphysis Misalignment / 耻骨错位:

Anterior-Posterior / 前后错位 Left-Right / 左右分离 Top-Bottom / 上下错位 Rotated / 旋转

Other / 其他:

Conclusion / 结论

Remarks / 备注:

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