Maternal postnatal 6 to 8 week check

Mental Health

Is motherhood everything you thought it would be? *

In the past month have you felt little interest or pleasure in doing things? *

In the past month haveyou often felt down, depressed or hopeless? *

During the past month have you been feeling anxious, nervous or on edge? *

During the past month have you not been able to stop or control worrying? *

Is this something we can help you with? *

RCGP Perinatal Mental Health Toolkit

Domestic Abuse

How are things at home? *

Have you ever felt frightened or had to change your behaviour due to someone you had a relationship with? *

Social Support

Who is at home to support you? *

Have you or your family ever received help or support from children’s services? *

How is your partner coping with parenthood? *

Postnatal Health Education

Do you feel your baby is crying excessively? *

Physical Health

Type of delivery: *

Feeding details: *

Would you like to start contraception? *

Yes

No

Which contraception? *

When was your last smear? *

Within the last 3 years

Over 3 years ago

Never had a smear

What is your smoking status? *

Never smoked

Used to smoke

Current smoker

Do you use drugs? *

Never used drugs

Used to use drugs

Currently use drugs

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

*

I confirm that the information provided is accurate to the best of my knowledge