1258 High Street, Eugene, OR 97401
Phone 541-342-8437 | Fax 541-242-2999
Name: Date:
As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.
For example, if the question is "I have felt happy", an answer of "Yes, most of the time" would mean "I have felt happy most of the time" in the past week. Please complete the other questions the same way.
In the past 7 days:
1. I have been able to laugh and see the funny side of things:
2. I have looked forward with enjoyment to things:
3. I have blamed myself unnecessarily when things went wrong
4. I have been anxious or worried for no good reason
5. I have felt scared of panicky for no very good reason
6. Things have been getting on top of me
7. I have been so unhappy that I have had difficulty sleeping
8. I have felt sad or miserable
9. I have been so unhappy that I have been crying
10. The thought of harming myself has occurred to me
