Miscarriage Survey Form Template

Must Ask Miscarriage Survey Questions

1. When did the loss occur, and what was the gestational age?

   Timing and gestation inform clinical risk and the urgency of follow-up. This context helps you tailor guidance and determine whether additional testing or a check-in is needed.

2. Where did you receive care, and did you understand your discharge instructions?

   Knowing the care setting pinpoints process gaps and partners to involve. Checking comprehension reveals which instructions or handouts need clearer language or translation.

3. What symptoms have you experienced since leaving care (e.g., bleeding, fever, pain), and how are they changing?

   Symptom trends help you triage quickly and flag red-flag events. This supports same-day outreach or escalation when safety is a concern.

4. How are you coping emotionally in the past two weeks, and would you like support or referrals?

   Emotional status guides timely referrals to counseling, groups, or telehealth. For a broader screen, you can pair this with the Psychology questionnaire form.

5. Do you need any documents or assistance (for work leave, insurance, or memorial options), and how may we contact you?

   This uncovers practical barriers and ensures you meet documentation needs without delay. Collecting preferred contact method and consent streamlines safe follow-up.