Please answer the following questions:

Full Name *

Email *

Phone *

Date of birth *

Baby's Date of Birth or Due Date *

State *

Emergency Contact Name *

Emergency Contact Number *

How did you hear about us? If from a provider (postcards, referral, etc), please list the provider and practice's name. *

*

I agree to receive SMS and Emails from Lunajoy

Text

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.

I have been able to laugh and see the funny side of things *

As much as I always could

Not quite so much now

Definitely not so much now

Not at all

I have looked forward with enjoyment to things *

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all

I have blamed myself unnecessarily when things went wrong *

Yes, most of the time

Yes, some of the time

Not very often

No, never

I have been anxious or worried for no good reason *

No, not at all

Hardly ever

Yes, sometimes

Yes, very often

I have felt scared or panicky for no very good reason *

Yes, quite a lot

Yes, sometimes

No, not much

No, not at all

Things have been getting on top of me *

Yes, most of the time I have not been able to cope at all

Yes, sometimes I have not been coping as well as usual

No, most of the time I have coped quite well

No, I have been coping as well as ever

I have been so unhappy that I have had difficulty sleeping *

Yes, most of the time

Yes, sometimes

Not very often

No, not at all

I have felt sad or miserable *

Yes, most of the time

Yes, quite often

Not very often

No, not at all

I have been so unhappy that I have been crying *

Yes, most of the time

Yes, quite often

Only occasionally

No, never

The thought of harming myself has occurred to me *

Yes, quite often

Sometimes

Hardly ever

Never

Over the past month, how often have you experienced the following?
Please check the response that most closely describes your experience.

Worry about the baby/pregnancy

Not at all

Sometimes

Often

Almost Always

Fear that harm will come to the baby

Not at all

Sometimes

Often

Almost Always

A sense of dread that something bad is going to happen

Not at all

Sometimes

Often

Almost Always

Sudden rushes of extreme fear or discomfort

Not at all

Sometimes

Often

Almost Always

Repetitive thoughts that are difficult to stop or control

Not at all

Sometimes

Often

Almost Always

Difficulty sleeping even when I have the chance to sleep

Not at all

Sometimes

Often

Almost Always

Wanting things to be perfect

Not at all

Sometimes

Often

Almost Always

Needing to be in control of things

Not at all

Sometimes

Often

Almost Always

Difficulty stopping checking or doing things over and over

Not at all

Sometimes

Often

Almost Always

Anxiety getting in the way of being able to do things

Not at all

Sometimes

Often

Almost Always

Full Name *

Email *

Phone *

Date of birth *

Baby's Date of Birth or Due Date *

State *

Emergency Contact Name *

Emergency Contact Number *

How did you hear about us? If from a provider (postcards, referral, etc), please list the provider and practice's name. *

*

I agree to receive SMS and Emails from Lunajoy

Text

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.

I have been able to laugh and see the funny side of things *

As much as I always could

Not quite so much now

Definitely not so much now

Not at all

I have looked forward with enjoyment to things *

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all

I have blamed myself unnecessarily when things went wrong *

Yes, most of the time

Yes, some of the time

Not very often

No, never

I have been anxious or worried for no good reason *

No, not at all

Hardly ever

Yes, sometimes

Yes, very often

I have felt scared or panicky for no very good reason *

Yes, quite a lot

Yes, sometimes

No, not much

No, not at all

Things have been getting on top of me *

Yes, most of the time I have not been able to cope at all

Yes, sometimes I have not been coping as well as usual

No, most of the time I have coped quite well

No, I have been coping as well as ever

I have been so unhappy that I have had difficulty sleeping *

Yes, most of the time

Yes, sometimes

Not very often

No, not at all

I have felt sad or miserable *

Yes, most of the time

Yes, quite often

Not very often

No, not at all

I have been so unhappy that I have been crying *

Yes, most of the time

Yes, quite often

Only occasionally

No, never

The thought of harming myself has occurred to me *

Yes, quite often

Sometimes

Hardly ever

Never

Over the past month, how often have you experienced the following?
Please check the response that most closely describes your experience.

Worry about the baby/pregnancy

Not at all

Sometimes

Often

Almost Always

Fear that harm will come to the baby

Not at all

Sometimes

Often

Almost Always

A sense of dread that something bad is going to happen

Not at all

Sometimes

Often

Almost Always

Sudden rushes of extreme fear or discomfort

Not at all

Sometimes

Often

Almost Always

Repetitive thoughts that are difficult to stop or control

Not at all

Sometimes

Often

Almost Always

Difficulty sleeping even when I have the chance to sleep

Not at all

Sometimes

Often

Almost Always

Wanting things to be perfect

Not at all

Sometimes

Often

Almost Always

Needing to be in control of things

Not at all

Sometimes

Often

Almost Always

Difficulty stopping checking or doing things over and over

Not at all

Sometimes

Often

Almost Always

Anxiety getting in the way of being able to do things

Not at all

Sometimes

Often

Almost Always