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perinatal anxiety Screen

MM slash DD slash YYYY
Name(Required)
MM slash DD slash YYYY
OVER THE PAST MONTH, How often have you experienced the following? Please tick the response that most closely describes your experience for every question.
1. Worry about the baby/pregnancy(Required)
2. Fear that harm will come to the baby(Required)
3. A sense of dread that something bad is going to happen(Required)
4. Worry about many things(Required)
5. Worry about the future(Required)
6. Feeling overwhelmed(Required)
7. Really strong fears about things, eg needles, blood, birth, pain, etc(Required)
8. Sudden rushes of extreme fear or discomfort(Required)
9. Repetitive thoughts that are difficult to stop or control(Required)
10. Difficulty sleeping even when I have the chance to sleep(Required)
11. Having to do things in a certain way or order(Required)
12. Wanting things to be perfect(Required)
13. Needing to be in control of things(Required)
14. Difficulty stopping checking or doing things over and over(Required)
15. Feeling jumpy or easily startled(Required)
16. Concerns about repeated thoughts(Required)
17. Being 'on guard' or needing to watch out for things(Required)
18. Upset about repeated memories, dreams or nightmares(Required)
19. Worry that I will embarrass myself in front of others(Required)
20. Fear that others will judge me negatively(Required)
21. Feeling really uneasy in crowds(Required)
22. Avoiding social activities because I might be nervous(Required)
23. Avoiding things which concern me(Required)
24. Feeling detached like you're watching yourself in a movie(Required)
25. Losing track of time and can't remember what happened(Required)
26. Difficulty adjusting to recent changes(Required)
27. Anxiety getting in the way of being able to do things(Required)
28. Racing thoughts making it hard to concentrate(Required)
29. Fear of losing control(Required)
30. Feeling panicky(Required)
31. Feeling agitated(Required)

Reference:

Somerville, S., Dedman, K., Hagan, R., Oxnam, E., Wettinger, M., Byrne, S., Coo, S., Doherty, D., Page, A.C. (2014).

The Perinatal Anxiety Screening Scale: development and preliminary validation. Archives of Women’s Mental Health, DOI: 10.1007/s00737-014-0425-8

Department of Health, State of Western Australia (2013).

Copyright to this material produced by the Western Australian Department of Health belongs to the State of Western Australia, under the provisions of the Copyright Act 1968 (Commonwealth of Australia). Apart from any fair dealing for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the Department of Psychological Medicine, Women and Newborn Health Service, WA Department of Health. Please acknowledge the authors and the WA Department of Health when reproducing or quoting material from this source.