Postpartum Mental Health Screening Questionnaire

Postpartum Mental Health Screening Questionnaire — Form Fields

This healthcare template includes 12 fields. Screening questionnaire for new mothers to assess postpartum mood and anxiety disorders. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Baby's Date of Birth (text, required)
• OB/GYN or Midwife Name (text, optional)
• Weeks Postpartum (dropdown selection, required) — options: 0-2 Weeks, 2-6 Weeks, 6-12 Weeks, 3-6 Months, 6-12 Months
• Delivery Experience (dropdown selection, required) — options: Vaginal - Uncomplicated, Vaginal - Complicated, Planned C-Section, Emergency C-Section
• History of Depression or Anxiety (multiple choice, required) — options: Yes, No
• Difficulty Bonding with Baby (multiple choice, required) — options: Yes, Sometimes, No
• Feeling Overwhelmed or Hopeless (multiple choice, required) — options: Often, Sometimes, Rarely, Never
• Thoughts of Harming Self or Baby (multiple choice, required) — options: Yes, No
• Support System (dropdown selection, required) — options: Strong, Moderate, Limited, None
• Additional Concerns (long text, optional)