Post Partum Depression Form

Edinburgh Postnatal Depression Scale (EPDS) Form
Baby's Name / Nombre del bebé(Required)
Mother's Name / Nombre de la madre(Required)
Mother's OBGYN's Last Name / Apellido del obstetra y ginecólogo de la madre
MM slash DD slash YYYY
MM slash DD slash YYYY

In the past 7 days:
1. I have been able to laugh and see the funny side of things / He podido reírme y ver el lado divertido de las cosas.(Required)
2. I have looked forward with enjoyment to things/ He esperado con gozo las cosas.(Required)
3. I have blamed myself unnecessarily when things went wrong. / Me he culpado innecesariamente cuando las cosas salieron mal.(Required)
4. I have been anxious or worried for no good reason / He estado ansiosa o preocupada por ninguna buena razón.(Required)
5. I have felt scared or panicky for no very good reason / Me he sentido asustado o en pánico sin una buena razón.(Required)
6. Things have been getting on top of me / Las cosas se han estado poniendo encima de mí.(Required)
7. I have been so unhappy that I have had difficulty sleeping / He sido tan infeliz que he tenido dificultad para dormir.(Required)
8. I have felt sad or miserable / Me he sentido triste o miserable.(Required)
9. I have been so unhappy that I have been crying / He sido tan infeliz que he estado llorando(Required)
10. The thought of harming myself has occurred to me / Se me ha ocurrido la idea de hacerme daño.(Required)

By providing this information, I give permission for PHS to relay my EPDS information to my OBGYN as identified above

*Source: Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Sclae. Br J Psychiatry. 1987;150:782-786.