MS-SN Postpartum Support Group Member Registration

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Email *

Name *

Best Telephone Number *

Address *

Is this a safe number to call? *

Yes

How did you find out about the group? *

Names and Ages of Children *

How do you feed your baby? *

Breastfeeding

Formula feeding

Expressed breastmilk in a bottle

I breastfeed and fomrula feed my baby

I prefer not to answer

What hospital did you deliver at? *

Do you work outside the home? *

Yes

If you answered yes, what type of work do you do? (if you answered no, type N/A) *

Are you planning or have you already gone back to work? *

Yes

N/A

Do you have family support/someone who is helping you out? *

Yes

Emergency Contact Information

Please list the name and information of the best person to contact you, in the case of an emergency.

Name *

Telephone number *

Relationship *

Personal History

Do you have a personal history and/or postpartum depression in the past? *

Yes

If you answered yes, please explain briefly (If no, reply N/A) *

Have you ever experienced pregnancy and/or postpartum depression in the past? *

Yes

Please describe how you are feeling. *

When did you begin to feel this way? *

Have you spoken to your doctor about how you are feeling? *

Yes

What type of treatment did they suggest? *

I am going to review a list of symptoms, and you can let me know if you are experiencing any of them. *

Frequent crying

Insomnia

Excessive sleeping

Loss of appetite

Increased appetite

Overconcern for baby

Underconcern for baby

Anxiety/Panic Attacks

Feelings of guilt or worthlessness

Feeling overwhelmed or unable to cope

Loss of interest in things you previously enjoyed

Angry/losing temper

Fear of harming self

Fear of harming baby

Fear of harming someone else

N/A

Other:

Required

If you answered "other" in the question above, please describe it. Otherwise, type "N/A" *

Do you currently feel suicidal? *

Yes

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