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Name ______________________________________________
Your date of birth __________________________________
Baby’s date of birth ________________________________
Address ______________________________________________
Phone number _______________________________________
As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today. Here is an example, already completed.
I have felt happy:
Yes, all the time
Yes, most of the time
This would mean: “I have felt happy most of the time” during the past week.
No, not very often
No, not at all
6. Things have been getting on top of me
As much as I always could
Yes, most of the time I haven’t been able to cope at all
Not quite so much now
Yes, sometimes I haven’t been coping as well
Definitely not so much now
No, most of the time I have coped quite well
Not at all
No, I have been coping as well as ever
2. I have looked forward with enjoyment to things
7. I have been so unhappy that I have had difficulty sleeping
As much as I ever did
Yes, most of the time
Rather less than I used to
Yes, sometimes
Definitely less than I used to
Not very often
Hardly at all
No, not at all
3. I have blamed myself unnecessarily when things went wrong
8. I have felt sad or miserable
Yes, most of the time
Yes, most of the time
Yes, some of the time
Yes, sometimes
Not very often
Not very often
No, never
No, not at all
4. I have been anxious or worried for no good reason
9. I have been so unhappy that I have been crying
No, not at all
Yes, most of the time
Hardly ever
Yes, quite often
Yes, sometimes
Only occasionally
Yes, very often
No, never
5. I have felt scared or panicky for no very good reason
10. The thought of harming myself has occurred to me
Yes, quite a lot
Yes, quite often
Yes, sometimes
Sometimes
No, not much
Hardly ever
No, not at all
Never
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Date ___________________________________________