History of mental health treatment | Text field |
---|---|
Pattern of alcohol consumption | Text field |
Illegal drug usage | Text field |
Drug support needed | Text field |
Currently on drug support | Text field |
“Is there someone to talk to about your feelings or worries?” | Yes / no / not sure / unable to ask |
“Will you be able to get practical support after the birth of your baby?” | Yes / no / not sure / unable to ask |
“In the last 12 months have you had any major worries, stress or change?” | no / financial difficulties / housing changes / relationship worries / significant isolation / loss or death / other / unable to ask |
“Generally do you consider yourself a confident person?” | No / yes / sometimes / unable to ask |
“Does it worry you a lot if things get messy or out of place?” | No / yes / sometimes / unable to ask |
“Have you ever felt anxious or depressed for more than 2 weeks?” | No / yes / unable to ask |
If yes, “did any episode seriously interfere with your work or relationships?” | No / yes |
And “were any of these episodes of anxiety related to pregnancy or birth?” | No / yes PND / yes – postnatal psychosis / other / not known |
Child living away | Text field |
Department of Community Services | Text field |
Frightened by partner | Text field |
Would you like assistance with this | Text field |
Response to DV questions | Text field |
Other issues or worries | Text field |
EDS total score | Text field |
Answer to EDS question 10 | Text field |
Psychosocial assessment – issues identified? | Text field |