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)
- Previous history of depression or anxiety
- Known history of bi-polar (manic-depressive) disorder in self or family
- Known history of PMS (premenstrual syndrome)
- Difficulties with past or current pregnancy, difficult birth, previous miscarriage or abortion
- Family history of abuse, neglect, alcohol or drug abuse
- History of sexual abuse
- Poor Mother-daughter or Father relationship
- High expectations of self and/or others
- High need to feel in control
- Low self-esteem
- Perfectionist tendencies
- Recent death of a loved one
- Unwanted pregnancy
- Unsupportive partner or family
- Recent separation or divorce
- Recent major move or life change (such as job)
- Unwanted medical interventions
- Financial difficulties
- History of Infertility
- 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:
- A sense of despair
- Feeling hopeless and powerless
- No energy or interests
- Loss of appetite or increase in appetite
- Sleeping too much or insomnia
- Frightening thoughts about the baby or other family members
- Weight loss or gain
- Feelings of guilt, shame
- Clumsiness
- Constant worries about the baby’s or your health
- Feeling inadequate
- Depressed mood
- Suicidal thoughts
- Muscle tension
- Rapid heartbeat
- Dizziness
- Hyperventilating/shortness of breath
- Difficulties trying to concentrate
- Continuous irritability
- Fear of being alone
- Nausea/vomiting
- Tingling/numbness
- Diarrhea
- Anger/rage
- Insomnia
- Agoraphobia (fear of leaving the house)
- Feeling trapped
- Fear of dying or death of baby or partner
- Acute shortness of breath
- Choking sensation
- Tightness in chest
- Fear of going crazy
- 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)
- Compulsive behaviors such as ritual cleaning, constant checks of the baby for abnormalities constant safety checks of the baby, house, etc.
- Intrusive memories of a trauma (past or present)
- Recurrent nightmares
- Flashbacks (reliving a past trauma)
- Hypervigilence about the baby
- Inability to relax
- Paranoia
- Incoherent thoughts or speech
- Hallucinations (auditory, tactile, or visual)
- Irrational thoughts
- Delusional thinking
- Manic behavior (High bursts of energy, rapid speech, little need for sleep or food, feeling you can accomplish super feats beyond normal abilities)
- Refusal to eat
- Can’tunderstand reality from fantasy