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THE POSTPARTUM STRESS CENTER

THE RASKIN-KLEIMAN POSTPARTUM DEPRESSION AND ANXIETY A+SSESSMENT

PLEASE NOTE: YOUR ANSWERS TO THIS QUESTIONNAIRE ARE A CONFIDENTIAL PART OF YOUR RECORD

NAME: _____________________________________________AGE: ______________

TODAYS DATE: _____________________
MARITAL STATUS:

_____Married
_____Separated
_____Divorced
_____Widowed
_____Single, not living with babys father
_____Single, living with babys father

Any previous marriage?

______No
_____Yes,
describe: __________________________________________________________
CHILDREN & AGES:

_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ _______________________________
OCCUPATION: (If full time homemaker list most recent occupation):

______________________________________________________________________________
EDUCATION: (check one)

_____Less than high school

_____Some high school
_____High school graduate
_____Some college
_____College graduate
_____Some graduate or post-college professional school
_____Graduate or professional degree
Please list any major childhood illness or surgical procedures, if any:
________________________________________
________________________________________
________________________________________
________________________________________
Please list any severe childhood stresses related to parents (divorce, separation, death):
________________________________________
________________________________________
________________________________________
How many weeks/months ago was you baby born? _____________________
What type of childbirth did you have?
1. Vaginal
2. Caesarian
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How much did your baby weigh at birth? _______ pounds ______ ounces
Check the statement that best describes how you remember your reaction to learning that you were pregnant:
_____The pregnancy was not planned, and I was happy to learn that I was pregnant.
_____The pregnancy was not planned, and I was unhappy to learn that I was pregnant.
_____The pregnancy was planned, and I was happy to learn that I was pregnant.
_____The pregnancy was planned, and I was unhappy to learn that I was pregnant.
IF THE PREGNANCY WAS PLANNED:

Did it take longer than a year to conceive the baby?

_____No
_____Yes
Did you receive treatment for infertility prior to conceiving the baby?
_____No
_____Yes
Any comments? ________________________________________________________________
Any previous abortions?
_____No
_____Yes
when? ________________________________
Have you suffered any previous miscarriages, stillbirth or infant loss?
_____No
_____Yes
please describe: _____________________________________________________
Do you have a history of PMS?
_____No
_____Yes,
describe: __________________________________________________________
Are you using birth control now?
_____No, not sexually active
_____No, trying to get pregnant
_____No, hope I dont get pregnant right now
_____Yes, sexually active
_____Yes, but not sexually active
If yes, please specify means of birth control: ___________________________________________
Was there anything outstanding or remarkable about your pregnancy?
______________________________________________________________________________
______________________________________________________________________________
Did you enjoy being pregnant?
_____No
_____Yes
What was your greatest fear during that time? _________________________________________
_____________________________________________________________________________
Were there any complications during the delivery?
_____No
_____Yes,
describe: __________________________________________________________
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Did your baby have any significant health problems at birth?
_____No
_____Yes,
describe: __________________________________________________________
Did you have any significant health problems related to childbirth?
_____No
_____Yes,
describe: __________________________________________________________
Please describe your feelings during the first few days about your baby:
______________________________________________________________________________
Please describe your feelings during the first few days about yourself:
______________________________________________________________________________
After going home, did you have help at home? (Check all that apply):
_____Husband
_____Mother
_____Mother-in-law
_____Nurse/Doula
_____Live-in-help
_____Housekeeper
_____Neighbor/friend
_____Other: ____________________________
At the time, did you feel that this help was adequate?
_____No
_____Yes
Do you have friends who have recently had a baby?
_____No
_____Yes
Please describe your babys general disposition:
_____________________________________________________________________________
How do you feel when you hear your baby cry? ________________________________________
_____________________________________________________________________________
Initial breastfeeding problems? (_____Not applicable)
1. ___________________________
2. ___________________________
3. ___________________________
How do you feel about breastfeeding? ________________________________________________
Initial bottlefeeding problems? (_____Not applicable)
1. __________________________
2. __________________________
3. __________________________
How are you feeding your baby now?
_____breastfeeding
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_____bottlefeeding
_____breastfeeding and bottlefeeding
_____started solids
Any feeding-related problems now?
_____No
_____Yes,
describe: __________________________________________________________
During the past week, what is the longest uninterrupted period of sleep that you have averaged each
night:___________________________
How much sleep did you usually require? (prior to pregnancy): _____ hours
Please describe your babys current sleep pattern: _______________________________________
Please check all statements that apply regarding your sleeping patterns:
_____Even when your baby sleeps, you wake several times
_____Youre usually so exhausted, you have no trouble sleeping
_____Sleep is a major problem in your life
_____Youre very tired, but you feel to agitated to sleep
_____You think youre sleeping too much
_____Youre not getting enough sleep
When your baby naps, what do you do?
1. _____________________________
2. _____________________________
3. _____________________________
Please list all prescribed medications that you have taken in any amount at all within the last month:
1. _________________________
2. _________________________
3. _________________________
Please list all over-the-counter medications that you have taken in any amount at all over the last month:
1. _________________________
2. _________________________
3. _________________________
Are you taking any herbal or homeopathic supplements at this time?
_____No
_____Yes,
please list: _________________________________________________________
Please describe typical daily caffeine intake:
_____#cups of coffee
_____#cups of tea
_____other: (chocolate): _________________________
Have you experienced any of the following within the past year?
_____Loss of parent
_____Loss of loved one other than parent
_____Life-threatening illness or other medical emergency to self or loved one
_____Divorce or separation
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_____Loss or change of job (self or spouse)
_____Move to new home
_____Other: (Please describe any event that you feel has impacted the way you are feeling now):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Have you ever been a victim of any of the following (Check all that apply):
_____Physical assault (being hit, kicked, punched, beat up) by a stranger
_____Physical assault by someone you know
_____Physical assault by someone you love
_____Sexual assault (actual or attempted forced vaginal, oral, or anal intercourse) by a stranger
_____Sexual assault by someone you know
_____Sexual assault by someone you love
_____Childhood physical abuse by a family member
_____Childhood physical abuse by someone else
_____Childhood sexual abuse (inappropriate touching or exposure) by a family member
_____Childhood sexual abuse by someone else
_____Physical assault during your most recent pregnancy
_____Sexual assault during your most recent pregnancy
Do you have any history of psychiatric or emotional problems?
_____No
_____Yes,
explain:____________________________________________________________
Have you ever received counseling?
_____No
_____Yes,
when? ________________ Any comments on your experience?________________
______________________________________________________________________________
Have you ever been hospitalized for psychiatric or emotional problems?
_____No
_____Yes,
when? ___________________ where? __________________________________
Have you ever been treated for substance abuse?
_____No
_____Yes,
when? ___________________ where? _________________________________
Have you ever taken psychiatric medication?
_____No
_____Yes,
what medication(s)? __________________________________________________
Did you find it helpful? ___________________________________________________________
Does anyone in your family (mother, father, brother, sister, grandparent, aunt, uncle, children) have any
history of psychiatric illness, treatment or hospitalization?
_____No
_____Yes,
describe:___________________________________________________________
Does anyone in your family have a history of chemical dependency, alcoholism or drug abuse?
_____No
_____Yes,
describe:___________________________________________________________
Does your partner have any history of psychiatric illness, treatment or hospitalization?
_____No
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_____Yes,

describe:___________________________________________________________

Does your partner have any history of chemical dependency, alcoholism or drug abuse?
_____No
_____Yes,
describe:___________________________________________________________
As far as you know, anyone in your family experience depression after the birth of her baby?
_____No
_____Yes,
describe:___________________________________________________________
Do you smoke?
_____No
_____Yes
approximate # per day _____
On the average, how many days per week do you drink any beer, wine, or alcohol? _____
On the days you have a drink, about how many drinks do you have? _____
In the past month, have you used any of the following for relaxation?
_____Marijuana
_____Cocaine
_____Other drugs
please specify: __________________________________________
What have you done in the past for relaxation or relief from stress? _________________________
Are you able to do this now?
_____No,
what gets in the way? _________________________________________________
_____Yes
What do you consider to be your greatest personal strength and resource at this time?
______________________________________________________________________
What do you consider to be your most limiting personal weakness at this time?
______________________________________________________________________
What would you change, if you could, about your partners role and participation in the care of your baby?
_________________________________________________________________________
What would you change, if you could, about your partners role and participation in his response to how you
are feeling? _____________________________________________________________
On a scale of 1 to 10, circle the number that best describes how you feel today:
1

This is the worst

I have ever felt

This is how I usually feel

10

This is the best I have ever felt

Please circle the number that best describes how close you feel to your baby emotionally right now:
1

Not close at all

Copyright 1994 Revised 2000 by The Postpartum Stress Center, LLC postpartumstress.com

10

Extremely close

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The next section explores the extent to which significant people in your life are helping you cope with the
stresses of having a new baby in the household. For the individuals listed, please respond to the four
questions below:
1. How comfortable are you

discussing feelings or thoughts

about your new baby and new
responsibilities with this person?
2. To what extent does this
person provide practical help
(such as helping with chores,
material things, practical advice?)

PARTNER
very uncomfortable

very little

3. To what extent does this person

give you emotional support by
1
listenting, talking, consoling, or just
being with you?

very little

4. Most people who have had a

new baby experience occasional
1
anxieties about their competence,
ability, self-worth. To what extent
has this person reassured you in
this area or would do that if you
needed it?

very little

MOTHER

very comfortable

very much

very much

very much

very uncomfortable

very comfortable

very little

very much

very little

very much

very little

very much

Below is a list of ways you might be feeling now. Please check all statements which describe the way you are
feeling:
_____ I cant shake these depressed feelings no matter what I do.
_____ I cry at least once a day.
_____ I feel sad most or all of the time.
_____ I cant concentrate or keep my mind on anything.
_____ I dont enjoy the things that I used to enjoy.
_____ I have no interest in making love at all, even though my doctor says its okay.
_____ I cant sleep even when my baby sleeps.
_____ I feel like a failure much of the time.
_____ I have no energy. I am tired all the time.
_____ I have no appetite and no enjoyment of food. (Or, I am having sugar cravings and compulsively eating
all the time.)
_____ I cant remember the last time I laughed.
_____ Every little thing gets on my nerves lately.
_____ I feel that the future is hopeless.
_____ It seems like I well feel this way forever.
_____ I have frightening or annoying thoughts that I cant get out of my mind (such as thinking I might hurt
my baby).
_____ I have panic (anxiety) attacks.
_____ I have felt that it would be better to be dead than to feel this way.
_____ I have felt that my family would be better off without me.
_____ I do things which seem senseless to me but which I cant seem to stop (such as washing my hands,
checking on the baby repeatedly, counting or checking things.)
_____ I am picked about dirt or germs, or cleaning compulsively.
_____ I am afraid to be alone or alone with the baby.
_____ I am afraid that I might harm myself in order to escape this pain.
_____ I am afraid I might actually do something to hurt my baby.
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_____ I am terrified that I might hurt my baby by accident or because I am feeling bad and not
concentrating.
_____ I hear sounds or voices when no one is really around.
_____ I do not feel that my thoughts are my own, that they are totally out of control or that something else is
controlling them.
_____ I have not slept at all in 48 hours.
_____ I do not feel loving toward my baby and cannot even go through the motions to care for him/her.
_____ I am rapidly losing weight without trying to.
_____ I am worried about my attachment to my baby.
_____ I have certain repeated thoughts, urges, or images that I know are ridiculous which I try to ignore or
get off my mind because they make me feel very anxious and uncomfortable.
Please specify:______________________________________________________
_____ I have certain acts which I must do in a particular way over and over again in order to avoid feeling
extremely uncomfortable.
Please specify:______________________________________________________
Sometimes.
_____ I cant catch my breath.
_____ My heart pounds.
_____ My hands shake or tremble.
_____ I have somach pains, nausea, or diarrhea.
_____ I get hot flashes or chills.
_____ I feel that something terrible is about to happen.
_____ I get dizzy or lightheaded.
_____ Things appear funny or unreal to me.
_____ I feel like Im on the outside looking in.
_____ I feel like Im choking or gagging.
_____ I feel like Im dying, or about to have a heart attack
_____ I am afraid to leave my house because I might have an anxiety attack and not be able to get help.
_____ I feel numb in my hands and/or around my mouth.
_____ I have other unexplained physical symptoms that I am worried about. Explain: ___________
Is there anything else you would like us to know? :

Copyright 1994 Revised 2000 by The Postpartum Stress Center, LLC postpartumstress.com

Copyright 1994 Revised 2000 by The Postpartum Stress Center, LLC postpartumstress.com