copy of original by blazemedia | May 17, 2022 | 0 comments Welcome to your Perinatal Wellness Questionnaire This is a wellness scale assessment questionnaire designed for new and expecting mothers. Firstly, please enter your name and email address below in order to allow for the results to be sent to you via email. Click "next" to begin the questionnaire. Full Name Email Perinatal Health Questionnaire - Part 1 Depression Scale - Part 1 We would like to know how you have been feeling in the past week. Please indicate which of the following comes closest to how you have been feeling over the past seven days, not just how you feel today. Please tick one circle for each question that comes closest to how you have felt in the last seven days. Q1. I have 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 None Q2. I have looked forward with enjoyment to things As much as I ever did Rather less than I used to Rather less than I used to Hardly at all None Q3. I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never None Q4. I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often None Q5. I have felt scared or panicky for no very good reason Yes, quite a lot Yes, sometimes No, not much No, not at all None Q6. Things have been getting on top of me Yes, most of the time I haven’t been able to cope at all 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 None Q7. I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all None Q8. I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all None Q9. I have been so unhappy that I have been cryin Yes, most of the time Yes, quite often Only occasionally No, never None Q10.The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never None Perinatal Health Questionnaire - Part 2 Depression Scale - Part 2 Q1. Have you ever had a period of 2 weeks or more when you felt particularly worried, miserable or depressed? If No, skip to Q1.c., if YES please answer please answer Q1.a., Q1.b. and Q1.c. No (If No, skip to Q1.c.) Yes (If Yes, please answer Q1.a., Q1.b. and Q1.c.,) None Q1.a. Did this seriously interfere with your work and your relationships with friends or family? Only answer this question if you answered Yes to Q1 Not at all A Little Somewhat Quite a lot Very Much None Q1.b. Did this lead you to seek professional help? Only answer this question if you answered Yes to Q1 Yes No None Did you see a psychiatrist, psychologist/counsellor, GP and/or did you take tablets/herbal medicine? If yes to seeing a professional, please provide name of professional: If yes to medicine, please provide list medication(s): Q1.c. Do you have any other history of mental health problems? (e.g. eating disorders, psychosis, bipolar, schizophrenia) No Yes None If yes, list other mental health problems: Q2. Is your relationship with your partner an emotionally supportive one? Very much Quite a lot Somewhat A little Not all No Partner None Q3. Have you had any stresses, changes or losses in the last 12 months? (e.g. only: separation, domestic violence, job loss, bereavement etc.) If NO, skip to Q4. If YES please answer Q3.a No (If No, skip to Q4) Yes (If Yes, please answer Q3.a) None If yes, please specify: Q3.a. How distressed were you by these stresses, changes Only Answer this part if you answered Q3 with yes Not at all A little Somewhat Quite alot Very Much None Q4. Would you generally consider yourself a worrier? Not at all A little Somewhat Quite a lot Very much None Q5. In general, do you become upset if you do not hot have order in your life? (e.g. regular timetable, tidy house) Not at all A little Somewhat Quite a lot Very Much None Q6. Do you feel you will have people you can depend on for support with your baby?. Do you feel you will have people you can depend on for support with your baby? Very much Quite alot Somewhat A little Not at all None Now you are having a baby, you may be starting to think about your own childhood and what it was like: Now you are having a baby, you may be starting to think about your own childhood and what it was like: Q7. Were you emotionally abused when you were growing up? No Yes None Q8. Have you ever been sexually or physically abused? No Yes None Q9. When you were growing did you feel your mother was emotionally supportive of you? Very much Quite alot Somewhat A little Not at all No Mother None Do you have any other concerns that you would like to talk about today Time's up
