| How many times have you been pregnant? _____ |
|
If you have NEVER been pregnant, SKIP to SECTION XXX BELOW. |
| How many of these pregnancies resulted in live births (including caesarean sections)? _____ |
| If NONE of your pregnancies resulted in a live birth, AND SKIP to SECTION XXX BELOW |
During how many of your pregnancies did you feel sad, miserable, or very anxious? By this we
mean a period of at least 2 weeks when you were not yourself and which was worse than the normal
ups and downs of life? _____ |
After how many of your deliveries, within the first six months postpartum, did you feel sad,
miserable, or very anxious? By this we mean a period of at least 2 weeks, when you were not
yourself and which was worse than the normal ups and downs of life? _____ |
Please think about the worst episode during pregnancy or after delivery.
During the worst episode of feeling sad, miserable, or very anxious during pregnancy or following
delivery, how often: |
|
Often Sometimes Rarely Never |
Did you feel able to laugh or see the funny side of things? ___ ___ ___ ___ Were you able to look forward to things with excitement? ___ ___ ___ ___ Did you blame yourself unnecessarily when things went wrong? ___ ___ ___ ___ Were you anxious or worried for no good reason? ___ ___ ___ ___ Did you feel scared or panicky for no good reason? ___ ___ ___ ___ Did you feel overwhelmed? ___ ___ ___ ___ Were you so unhappy that you had difficulty sleeping? ___ ___ ___ ___ Did you feel sad or miserable? ___ ___ ___ ___ Were you so unhappy that you cried? ___ ___ ___ ___ Did the thought of harming yourself occur to you? ___ ___ ___ ___ |
Severity and Timing of Onset: During the worst episode of feeling sad, miserable, or very anxious
during pregnancy or following delivery: |
|
Yes No |
Were the symptoms so severe that you sought professional help? ___ ___ Did the symptoms cause you problems or interfere with your day-to-day life? ___ ___ Did you require psychiatric hospitalization because of these symptoms? ___ ___ -
Did you receive any form of treatment such as counseling or medication because of depression during pregnancy or following delivery?__
No Treatment __Counseling __Medication __Counseling and Medication
During the worst episode, when did these symptoms begin? During Pregnancy: __1st trimester __2nd trimester __3rd trimester After Delivery: __0–4 weeks __1–3 months __more than 3 months postpartum During the worst episode, how long did these symptoms last? ___ Up to 2 weeks ___2–4 weeks ___1–3 months ___3–6 months ___ more than 6 months How old were you during the worst episode? _____
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