Postpartum Depression Scale – Rising Star Pediatrics

Postnatal depression screening

Rising Star Pediatrics · Fax: 561-916-0414 · rspeds.com

Patient information

About you and your baby.

Your name *

Date *

Baby's age

Please answer each question based on how you have felt in the past 7 days, not just how you feel today.

Mood & outlook

Questions 1–3 of 10

Anxiety & coping

Questions 4–6 of 10

Sleep & wellbeing

Questions 7–10 of 10

Review & submit

Please review your answers before submitting.

I confirm that the information provided is accurate and complete to the best of my knowledge. I understand this form is stored securely and will be automatically deleted after 14 days.

✓

Screening submitted

Thank you for completing this questionnaire. Your responses have been received by Rising Star Pediatrics. Dr. Marie will review them before your next visit.

Your submission is encrypted and will be automatically deleted after 14 days. No patient information was sent via email.

This screening tool does not diagnose depression. It is reviewed by a licensed health care provider.