Postpartum Depression Self-Report Screening Form
Personal Information
Name:
Age:
Date:
Screening Questions
During the past week, have you 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
Have you 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
Have you blamed yourself unnecessarily when things went wrong?
No, never
Not very often
Yes, some of the time
Yes, most of the time
Have you been anxious or worried for no good reason?
No, not at all
Hardly ever
Yes, sometimes
Yes, very often
Have you felt scared or panicky for no good reason?
No, not at all
No, not much
Yes, sometimes
Yes, quite a lot
Have you been so unhappy that you have had difficulty sleeping?
No, not at all
Not very often
Yes, sometimes
Yes, most of the time
Have you felt sad or miserable?
No, not at all
Not very often
Yes, quite often
Yes, most of the time
Have you been so unhappy that you have been crying?
No, never
Only occasionally
Yes, quite often
Yes, most of the time
Have you thought of harming yourself?
Never
Hardly ever
Sometimes
Yes, quite often
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