Date MM slash DD slash YYYY Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY OVER THE PAST MONTH, How often have you experienced the following? Please tick the response that most closely describes your experience for every question.1. Worry about the baby/pregnancy(Required) Not at all Some times Often Almost Always 2. Fear that harm will come to the baby(Required) Not at all Some times Often Almost Always 3. A sense of dread that something bad is going to happen(Required) Not at all Some times Often Almost Always 4. Worry about many things(Required) Not at all Some times Often Almost Always 5. Worry about the future(Required) Not at all Some times Often Almost Always 6. Feeling overwhelmed(Required) Not at all Some times Often Almost Always 7. Really strong fears about things, eg needles, blood, birth, pain, etc(Required) Not at all Some times Often Almost Always 8. Sudden rushes of extreme fear or discomfort(Required) Not at all Some times Often Almost Always 9. Repetitive thoughts that are difficult to stop or control(Required) Not at all Some times Often Almost Always 10. Difficulty sleeping even when I have the chance to sleep(Required) Not at all Some times Often Almost Always 11. Having to do things in a certain way or order(Required) Not at all Some times Often Almost Always 12. Wanting things to be perfect(Required) Not at all Some times Often Almost Always 13. Needing to be in control of things(Required) Not at all Some times Often Almost Always 14. Difficulty stopping checking or doing things over and over(Required) Not at all Some times Often Almost Always 15. Feeling jumpy or easily startled(Required) Not at all Some times Often Almost Always 16. Concerns about repeated thoughts(Required) Not at all Some times Often Almost Always 17. Being 'on guard' or needing to watch out for things(Required) Not at all Some times Often Almost Always 18. Upset about repeated memories, dreams or nightmares(Required) Not at all Some times Often Almost Always 19. Worry that I will embarrass myself in front of others(Required) Not at all Some times Often Almost Always 20. Fear that others will judge me negatively(Required) Not at all Some times Often Almost Always 21. Feeling really uneasy in crowds(Required) Not at all Some times Often Almost Always 22. Avoiding social activities because I might be nervous(Required) Not at all Some times Often Almost Always 23. Avoiding things which concern me(Required) Not at all Some times Often Almost Always 24. Feeling detached like you're watching yourself in a movie(Required) Not at all Some times Often Almost Always 25. Losing track of time and can't remember what happened(Required) Not at all Some times Often Almost Always 26. Difficulty adjusting to recent changes(Required) Not at all Some times Often Almost Always 27. Anxiety getting in the way of being able to do things(Required) Not at all Some times Often Almost Always 28. Racing thoughts making it hard to concentrate(Required) Not at all Some times Often Almost Always 29. Fear of losing control(Required) Not at all Some times Often Almost Always 30. Feeling panicky(Required) Not at all Some times Often Almost Always 31. Feeling agitated(Required) Not at all Some times Often Almost Always ScoreReference: Somerville, S., Dedman, K., Hagan, R., Oxnam, E., Wettinger, M., Byrne, S., Coo, S., Doherty, D., Page, A.C. (2014). The Perinatal Anxiety Screening Scale: development and preliminary validation. Archives of Women’s Mental Health, DOI: 10.1007/s00737-014-0425-8 Department of Health, State of Western Australia (2013). Copyright to this material produced by the Western Australian Department of Health belongs to the State of Western Australia, under the provisions of the Copyright Act 1968 (Commonwealth of Australia). Apart from any fair dealing for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the Department of Psychological Medicine, Women and Newborn Health Service, WA Department of Health. Please acknowledge the authors and the WA Department of Health when reproducing or quoting material from this source.
