Risk Evaluation for Postpartum Mood Disorders

NAME:DATE:

NOTE: This is not to be used as a diagnostic tool. It is merely a guide to indicate if there may be some areas of concern to identify and expedite any need for professional help in coping with potential pregnancy or postpartum mood disorders.

Have you in the past or are you now experiencing the following: (Please check all that apply)

  1. Previous history of depression or anxiety
  2. Known history of bi-polar (manic-depressive) disorder in self or family
  3. Known history of PMS (premenstrual syndrome)
  4. Difficulties with past or current pregnancy, difficult birth, previous miscarriage or abortion
  5. Family history of abuse, neglect, alcohol or drug abuse
  6. History of sexual abuse
  7. Poor Mother-daughter or Father relationship
  8. High expectations of self and/or others
  9. High need to feel in control
  10. Low self-esteem
  11. Perfectionist tendencies
  12. Recent death of a loved one
  13. Unwanted pregnancy
  14. Unsupportive partner or family
  15. Recent separation or divorce
  16. Recent major move or life change (such as job)
  17. Unwanted medical interventions
  18. Financial difficulties
  19. History of Infertility
  20. Employment difficulties

The following is a broad list of potential symptoms you may experience with a prenatal or postpartum mood disorder. Please check any that you may be experiencing:

  1. A sense of despair
  2. Feeling hopeless and powerless
  3. No energy or interests
  4. Loss of appetite or increase in appetite
  5. Sleeping too much or insomnia
  6. Frightening thoughts about the baby or other family members
  7. Weight loss or gain
  8. Feelings of guilt, shame
  9. Clumsiness
  10. Constant worries about the baby’s or your health
  11. Feeling inadequate
  12. Depressed mood
  13. Suicidal thoughts
  14. Muscle tension
  15. Rapid heartbeat
  16. Dizziness
  17. Hyperventilating/shortness of breath
  18. Difficulties trying to concentrate
  19. Continuous irritability
  20. Fear of being alone
  21. Nausea/vomiting
  22. Tingling/numbness
  23. Diarrhea
  24. Anger/rage
  25. Insomnia
  26. Agoraphobia (fear of leaving the house)
  27. Feeling trapped
  28. Fear of dying or death of baby or partner
  29. Acute shortness of breath
  30. Choking sensation
  31. Tightness in chest
  32. Fear of going crazy
  33. Intrusive obsessive thoughts (frequent thoughts you cannot shut out of your mind or “mind racing”) that bring on feelings of fear, shame, guilt, inadequacy or embarrassment (for instance, feeling you’re not a good mother)
  34. Compulsive behaviors such as ritual cleaning, constant checks of the baby for abnormalities constant safety checks of the baby, house, etc.
  35. Intrusive memories of a trauma (past or present)
  36. Recurrent nightmares
  37. Flashbacks (reliving a past trauma)
  38. Hypervigilence about the baby
  39. Inability to relax
  40. Paranoia
  41. Incoherent thoughts or speech
  42. Hallucinations (auditory, tactile, or visual)
  43. Irrational thoughts
  44. Delusional thinking
  45. Manic behavior (High bursts of energy, rapid speech, little need for sleep or food, feeling you can accomplish super feats beyond normal abilities)
  46. Refusal to eat
  47. Can’tunderstand reality from fantasy