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.
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16.
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
17.
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42.
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)
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’t understand reality from fantasy