Cognitive Symptoms

Please select all that apply.

Anxiety

Confusion

Memory Loss

Difficulty concentrating

Difficulty making decisions

Behavioral Symptoms

Please select all that apply.

Sleeping all of the time

Trouble falling or staying asleep

Loss of appetite

Unable to force myself to eat

Crying all the time

Excessive alcohol in my diet

Excessive junk food in my diet

Overly attached to partner

Overly attached to baby or completely detached from baby

Physical Symptoms

Please select all that apply.

Tightness in your chest or chest pain

Heart palpitations

Difficulty breathing

Lack of energy

Restlessness

Dizziness

Headaches

Nausea

Vomiting

Diarrhea

Hot or cold flashes

Shakiness

Panic attacks

Loss of sexual interest

Emotional Symptoms

Please select all that apply.

Nervous

Angry, even full of rage, at times

Irritable

Frustrated

Overwhelmed

Sad

Guilty

Hopeless

Worthless

Inadequate

Unable to cope

Unresponsive / numb

Uninterested in doing anything pleasurable

Unable to get pleasure from doing things I used to get pleasure from

Fearful

Afraid to be alone with the baby

Nervous about ability to care for baby

Sometimes I think...

Please select all that apply.

I am a bad mom

I shouldn't have had a baby

This is the worst I have ever felt

Things will never get better

I don't think I can do this by myself

I just want to run away

I wish I didn't have to be here

My child/spouse would be better off without me

Scary thoughts about my baby

Scary thoughts about myself

Scary thoughts about others

About harming myself

About harming my baby or child

I am afraid to tell anyone about my thoughts or feelings

Consent to contact *

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Name *

First Name

Last Name

Acknowledgement *

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I live in either Illinois, Wisconsin, Iowa, or Indiana.