Section 1 of 8
Perceived Traumatic Birth Screening Tool
Section 2 of 8
Chart Information
Name:
Name:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Age:
Age:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
10
2.
11
3.
12
4.
13
5.
14
6.
15
7.
16
8.
17
9.
18
10.
19
11.
20
12.
21
13.
22
14.
23
15.
24
16.
25
17.
26
18.
27
19.
28
20.
29
21.
30
22.
31
23.
32
24.
33
25.
34
26.
35
27.
36
28.
37
29.
38
30.
39
31.
40
32.
41
33.
42
34.
43
35.
44
36.
45
37.
46
38.
47
39.
48
40.
49
41.
50
42.
51
43.
52
44.
53
45.
54
46.
55
47.
Add option
…
Answer key
(0 points)
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Gender:
Gender:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Female
2.
Male
3.
Non-binary
4.
Other
5.
Add option
…
Answer key
(0 points)
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Room number:
Room number:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
240 PP
2.
241 PP
3.
242 PP
4.
243 PP
5.
244 PP
6.
245 PP
7.
246 PP
8.
247 PP
9.
248 PP
10.
249 PP
11.
250 PP
12.
251 PP
13.
252 PP
14.
253 PP
15.
254 PP
16.
255 PP
17.
256 PP
18.
257 PP
19.
258 PP
20.
259 PP
21.
260 PP
22.
261 PP
23.
262 PP
24.
263 PP
25.
264 PP
26.
265 PP
27.
266 PP
28.
267 PP
29.
268 PP
30.
269 PP
31.
270 PP
32.
271PP
33.
272 PP
34.
273 PP
35.
274 PP
36.
275 PP
37.
276 PP
38.
277 PP
39.
278 PP
40.
279 PP
41.
280 PP
42.
1 LDR
43.
2 LDR
44.
3 LDR
45.
4 LDR
46.
5 LDR
47.
6 LDR
48.
7 LDR
49.
8 LDR
50.
9 LDR
51.
10 LDR
52.
A LDTR
53.
B LDTR
54.
C LDTR
55.
D LDTR
56.
Other
57.
Add option
…
Answer key
(0 points)
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Reason for hospital admit:
Reason for hospital admit:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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BMI:
BMI:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Less than 10
2.
10
3.
11
4.
12
5.
13
6.
14
7.
15
8.
16
9.
17
10.
18
11.
19
12.
20
13.
21
14.
22
15.
23
16.
24
17.
25
18.
26
19.
27
20.
28
21.
29
22.
30
23.
31
24.
32
25.
33
26.
34
27.
35
28.
36
29.
37
30.
38
31.
39
32.
40
33.
41
34.
42
35.
43
36.
44
37.
45
38.
46
39.
47
40.
48
41.
49
42.
50
43.
More than 50
44.
Unknown at this time
45.
Add option
…
Answer key
(0 points)
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Gravida/parity:
Gravida/parity:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Ectopic
S. abortion
I. abortion
Multi b. pregnancies
Gravida
Para f. term
Para p. term
Abortions
Living
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Other
Rows
1.
0
2.
1
3.
2
4.
3
5.
4
6.
5
7.
6
8.
7
9.
8
10.
9
11.
10
12.
11
13.
12
14.
13
15.
14
16.
15
17.
16
18.
17
19.
18
20.
19
21.
20
22.
Other
23.
Add row
Columns
Ectopic
S. abortion
I. abortion
Multi b. pregnancies
Gravida
Para f. term
Para p. term
Abortions
Living
Add column
…
Answer key
(0 points)
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Section 3 of 8
Contact Information
Address:
Address:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Phone number:
Phone number:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Email address:
Email address:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Section 4 of 8
Patient Demographics
Race:
Race:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
White
2.
Black
3.
Pacific Islander
4.
Asian
5.
Native American
6.
Other
7.
N/A
8.
Add option
…
Answer key
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Ethnicity:
Ethnicity:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Hispanic
2.
Non-hispanic
3.
Other
4.
N/A
5.
Add option
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Answer key
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Marital status:
Marital status:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Married
Life partner
Single
Separated
Divorced
Widowed
Other…
Add option
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Answer key
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Section 5 of 8
Birth Information
Date of delivery:
Date of delivery:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Time of delivery:
Time of delivery:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Time of delivery baby B:
Time of delivery baby B:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Time of delivery baby C:
Time of delivery baby C:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Attending:
Attending:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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L&D nurse:
L&D nurse:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Delivery type:
Delivery type:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Vaginal - no epidural
2.
Vaginal - epidural
3.
Forceps assisted - no epidural
4.
Forceps assisted - epidural
5.
Vacuum assisted - no epidural
6.
Vacuum assisted - epidural
7.
Emergency C-section
8.
Planned C-section
9.
Vaginal birth after cesarean - epidural
10.
Vaginal birth after cesarean -no epidural
11.
Birth outside of hospital, t/f > hospital
12.
Other
13.
Add option
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Answer key
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Damage to perineal area:
Damage to perineal area:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
n/a - C-section
2.
No
3.
Yes - episiotomy
4.
Yes - laceration
5.
Add option
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Answer key
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Estimated gestational age:
Estimated gestational age:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
less than 18 weeks
2.
18 weeks
3.
19 weeks
4.
20 weeks
5.
21 weeks
6.
22 weeks
7.
23 weeks
8.
24 weeks
9.
25 weeks
10.
26 weeks
11.
27 weeks
12.
28 weeks
13.
29 weeks
14.
30 weeks
15.
31 weeks
16.
32 weeks
17.
33 weeks
18.
34 weeks
19.
35 weeks
20.
36 weeks
21.
37 weeks
22.
38 weeks
23.
39 weeks
24.
40 weeks
25.
41 weeks
26.
42 weeks
27.
More than 42 weeks
28.
Add option
…
Answer key
(0 points)
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Neonatal outcome:
Neonatal outcome:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Miscarriage
2.
Stillbirth
3.
Live birth
4.
Death shortly after birth
5.
Other
6.
Add option
…
Answer key
(0 points)
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Neonate weight:
Neonate weight:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
kg
kg
0
1
2
3
4
5
6
7
8
9
10
0
Label (optional)
6
Label (optional)
Answer key
(0 points)
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Neonate weight baby B:
Neonate weight baby B:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
kg
kg
0
1
2
3
4
5
6
7
8
9
10
0
Label (optional)
6
Label (optional)
Answer key
(0 points)
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Neonate weight baby C:
Neonate weight baby C:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
kg
kg
0
1
2
3
4
5
6
7
8
9
10
0
Label (optional)
6
Label (optional)
Answer key
(0 points)
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APGAR score:
APGAR score:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
1
2.
2
3.
3
4.
4
5.
5
6.
6
7.
7
8.
8
9.
9
10.
N/A
11.
Add option
…
Answer key
(0 points)
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APGAR score baby B:
APGAR score baby B:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
1
2.
2
3.
3
4.
4
5.
5
6.
6
7.
7
8.
8
9.
9
10.
N/A
11.
Add option
…
Answer key
(0 points)
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APGAR score baby C:
APGAR score baby C:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
1
2.
2
3.
3
4.
4
5.
5
6.
6
7.
7
8.
8
9.
9
10.
N/A
11.
Add option
…
Answer key
(0 points)
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Feeding plan:
Feeding plan:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Breastmilk
2.
Formula
3.
Breastmilk and formula
4.
other
5.
n/a
6.
Add option
…
Answer key
(0 points)
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Length of labor:
Length of labor:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
N/A - C-section
2.
Less than 1 hour
3.
1 hour
4.
2 hours
5.
3 hours
6.
4 hours
7.
5 hours
8.
6 hours
9.
7 hours
10.
8 hours
11.
9 hours
12.
10 hours
13.
11 hours
14.
12 hours
15.
13 hours
16.
14 hours
17.
15 hours
18.
16 hours
19.
17 hours
20.
18 hours
21.
19 hours
22.
20 hours
23.
21 hours
24.
22 hours
25.
23 hours
26.
24 hours
27.
25 hours
28.
26 hours
29.
27 hours
30.
28 hours
31.
29 hours
32.
30 hours
33.
31 hours
34.
32 hours
35.
33 hours
36.
34 hours
37.
35 hours
38.
36 hours
39.
37 hours
40.
38 hours
41.
39 hours
42.
40 hours
43.
41 hours
44.
42 hours
45.
43 hours
46.
44 hours
47.
45 hours
48.
46 hours
49.
47 hours
50.
48 hours
51.
49 hours
52.
50 hours
53.
51 hours
54.
52 hours
55.
53 hours
56.
54 hours
57.
55 hours
58.
56 hours
59.
57 hours
60.
58 hours
61.
59 hours
62.
60 hours
63.
61 hours
64.
62 hours
65.
63 hours
66.
64 hours
67.
65 hours
68.
66 hours
69.
67 hours
70.
68 hours
71.
69 hours
72.
70 hours
73.
71 hours
74.
72 hours
75.
73 hours +
76.
Add option
…
Answer key
(0 points)
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Written birth plan:
Written birth plan:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
N/A
4.
Add option
…
Answer key
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Baby for adoption:
Baby for adoption:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
Undecided
4.
n/a
5.
Add option
…
Answer key
(0 points)
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Surrogate pregnancy:
Surrogate pregnancy:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
n/a
4.
Add option
…
Answer key
(0 points)
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Complications (select all that apply):
Complications (select all that apply):
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
None
Failure to progress
Fetal distress
Perinatal asphyxia
Shoulder dystocia
Excessive bleeding
Malposition
Placenta previa
Cephalopelvic disproportion
Uterine rupture
Rapid labor
Incompetent cervix
Premature rupture of membranes
Premature labor
Hypertenesion
Postdate
Meconium staining
Drug abuse during pregnancy
Gestational diabetes
Polyhydrmnios
Cord abnormalities
HELPP syndrome
Other…
Add option
…
Answer key
(0 points)
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NICU stay:
NICU stay:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes
No
Pending
n/a
Add option
or
add "Other"
…
Answer key
(0 points)
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NICU stay baby B:
NICU stay baby B:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes
No
Pending
n/a
Add option
or
add "Other"
…
Answer key
(0 points)
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NICU stay baby C:
NICU stay baby C:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes
No
Pending
n/a
Add option
or
add "Other"
…
Answer key
(0 points)
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Section 6 of 8
Interview Date and Time
Date:
Date:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Time:
Time:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Numeric pain scale
Numeric pain scale
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
0
2.
1
3.
2
4.
3
5.
4
6.
5
7.
6
8.
7
9.
8
10.
9
11.
10
12.
n/a
13.
Add option
…
Answer key
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Section 7 of 8
Perceived Traumatic Birth Screening Tool
Did you worry that you or your baby were at risk of death during the birthing process?
Did you worry that you or your baby were at risk of death during the birthing process?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
n/a
4.
Add option
…
Answer key
(0 points)
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Did you worry that you or your baby were at risk of serious injury during the birthing process?
Did you worry that you or your baby were at risk of serious injury during the birthing process?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
n/a
4.
Add option
…
Answer key
(0 points)
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Do you feel like your labor was hard and upsetting?
Do you feel like your labor was hard and upsetting?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
n/a
4.
Add option
…
Answer key
(0 points)
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Did you feel frightened or helpless during your labor?
Did you feel frightened or helpless during your labor?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
n/a
4.
Add option
…
Answer key
(0 points)
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Section 8 of 8
Interventions and Resources Provided
Skin-to-skin contact in the first two hours after giving birth:
Skin-to-skin contact in the first two hours after giving birth:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
None
2.
Less than half an hour
3.
Between 30 min and 60 min
4.
Between 60 min and 90 min
5.
Between 90 min and 120 min
6.
More than two hours
7.
Add option
…
Answer key
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VIsuospatial cognitive intervention for 15 min within 6 hours of giving birth (sound turned off):
VIsuospatial cognitive intervention for 15 min within 6 hours of giving birth (sound turned off):
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
None
2.
Tetris
3.
Candy Crush
4.
Word Search
5.
Picture find
6.
n/a
7.
Add option
…
Answer key
(0 points)
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Access to www.happybirthdayprogram.com was given:
Access to www.happybirthdayprogram.com was given:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
n/a
4.
Add option
…
Answer key
(0 points)
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Transition planning was provided:
Transition planning was provided:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
n/a
4.
Add option
…
Answer key
(0 points)
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Ergonomics training was provided:
Ergonomics training was provided:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
n/a
4.
Add option
…
Answer key
(0 points)
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Safe infant handling training was provided:
Safe infant handling training was provided:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
1.
Yes
2.
No
3.
n/a
4.
Add option
…
Answer key
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Educated on breathing techniques for stress reduction:
Educated on breathing techniques for stress reduction:
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