Postpartum Depression Screening Form
Full Name
Date of Birth
Today's Date
Baby's Date of Birth
In the past 7 days, how often have you…
1. Been able to laugh and see the funny side of things?
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
2. Looked forward with enjoyment to things?
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
3. Blamed yourself unnecessarily when things went wrong?
Yes, most of the time
Yes, some of the time
Not very often
No, never
4. Been anxious or worried for no good reason?
Yes, very often
Yes, sometimes
Hardly ever
No, never
5. Felt scared or panicky for no very good reason?
Yes, quite a lot
Yes, sometimes
No, not much
No, not at all
6. Things have been getting on top of you?
Yes, most of the time
Yes, sometimes I haven’t been coping as well as usual
No, most of the time I have coped quite well
No, I have been coping as well as ever
7. Been so unhappy that you have had difficulty sleeping?
Yes, most of the time
Yes, sometimes
Not very often
No, not at all
8. Felt sad or miserable?
Yes, most of the time
Yes, some of the time
Not very often
No, not at all
9. Been so unhappy that you have been crying?
Yes, most of the time
Yes, quite often
Only occasionally
No, never
10. The thought of harming myself has occurred to me
Yes, quite often
Sometimes
Hardly ever
Never
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