Self Assessment Questionnaire:

This questionnaire was prepared by the Women’s Reproductive Mental Health Program at Credit Valley Hospital to help women self assess their risk for depression during pregnancy or postpartum so they can discuss their concerns with their physician(Family Doctor, Obstetrician and/or Pediatrician) to facilitate a referral to the program.


1) Have you ever been diagnosed or treated for Depression/Anxiety? Yes No
2) Do you have a history of Postpartum Depression? Yes No
3) Have you noticed a decline in your mood or functioning in the last 2 weeks? Yes No
4) Are there stressful events in your life? Yes No
5) Are you concerned about lack of support for you?
(family, friends or neighbours)?		 Yes No

If at any time during your pregnancy or after giving birth, you have answered Yes to any of questions 1 – 5 you may benefit from the services provided by the Women’s Reproductive Mental Health Program. Please discuss this questionnaire with your physician to help initiate a referral.