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I. Lack of support
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1. Will you be able to get practical support with your baby?
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2. Do you have someone you are able to talk to about your feelings or worries?
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II. Recent major stressors in the last 12 months.
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3. Have you had any major stressors, changes or losses recently (i.e., in the last 12 months) such as, financial problems, someone close to you dying, or any other serious worries?
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III. Low self-esteem (including lack of self-confidence, high anxiety and perfectionist traits)
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4. Generally, do you consider yourself a confident person?
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5. Does it worry you a lot if things get messy or out of place?
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IV. History of anxiety, depression or other mental health problems
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6a. Have you ever felt anxious, miserable, worried or depressed for more than a couple of weeks?
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6b. If so, did it seriously interfere with your work and your relationships with friends and family?
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7. Are you currently receiving, or have you in the past received treatment for any emotional problems?
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V. Couple’s Relationship Problems or Dysfunction (if applicable)
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8. How would you describe your relationship with your partner?
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9. a) Antenatal: What do you think your relationship will be like after the birth?
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OR
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b) Postnatal (in Community Health Setting): Has your relationship changed since having the baby?
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VI. Adverse childhood experiences
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10. Now that you are having a child of your own, you may think more about your own childhood and what it was like. As a child were you hurt or abused in any way (physically, emotionally, sexually)?
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VII. Domestic violence (DV) Questions must be asked only when the woman can be interviewed away from partner or family member over the age of 3 years. Staff must undergo training in screening for domestic violence before administering questions
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11. Within the last year have you been hit, slapped, or hurt in other ways by your partner or ex-partner?
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12. Are you frightened of your partner or ex-partner? (If the response to questions 11 and 12 is “No” then offer the DV information card and omit questions 13–18)
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13. Are you safe here at home?/to go home when you leave here?
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14. Has your child/children been hurt or witnessed violence?
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15. Who is/are your children with now?
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16. Are they safe?
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17. Are you worried about your child/children’s safety?
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18. Would you like assistance with this?
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Opportunity to disclose further
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19. Are there any other issues or worries you would like to mention?
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