Section 1: Contact and Demographic Information

Participant ID#

Email

Phone

Address (including time zone)

Marital Status

MarriedSinglePartneredDivorcedOther

Ethnic Heritage

Is English your first language?

YesNo

If no, what is your primary language?

Section 2: Pregnancy and Birth Details

Is this your first pregnancy?

YesNo

Expected Due Date

Is this your first child?

YesNo

If not, how many other children do you have?

Have you done any prenatal genetic testing?

YesNo

If yes, please describe

Have you had an ultrasound?

YesNo

If yes, how many and any notable findings?

Have you been tested for gestational diabetes?

YesNo

If yes, results

Planned birth setting

HospitalBirthing CenterHome Birth

Do you plan to have a doula?

YesNo

If yes, please specify

Will your partner attend the birth?

YesNo

Will your partner take time off after birth?

YesNo

If yes, how much time?

How much postpartum time off will you have (weeks)?

Are you planning to do any traditional postpartum practices passed
down from your family, heritage, or culture?

YesNo

If yes, please describe

Section 3: Home Life and Support System

Is the child's father living in the home?

YesNo

Employment status

Full-timePart-timeNot employed

Do you work at home or outside?

At homeOutside the home

Do you have a support system?

YesNo

Please explain

Do you have family support nearby?

YesNo

If yes, how will they assist?

Do you prepare meals at home?

Yes, most daysSometimesRarelyNo partner / No

Can you prepare and freeze foods?

YesNo

If no, please explain

Can you purchase special foods/supplies (~$100)?

YesNo

If no, please explain

Can you commit to the full 40-day healing protocol?

YesNo

Section 4: Health History and Current Health

Height

Weight

Last known vitals, ex. blood pressure, pulse, O2 levels

Current medications or supplements

Family history of depression?

YesNo

If yes, describe

Personal history of depression?

YesNo

If yes, describe

History of drug or alcohol addiction?

YesNo

If yes, describe

Injuries, pain, or medical conditions

Allergies (food, medication, environmental)

Food dislikes or constraints

Have you done recent bloodwork for depression markers?

YesNo

If yes, results or dates

Section 5: Lifestyle and Self-Care

Pre-pregnancy lifestyle

Very activeModerately activeNot very active

How many times a week do you exercise?

Self-care activities

Do you feel better with self-care?

YesNoSometimes

Is it hard to fit self-care in?

YesNoSometimes

Biggest concern after baby arrives

Section 6: Emotional Check-In (Past 7 Days)

1. I have been able to laugh and see the funny side of things

As much as I always couldNot quite so much nowDefinitely not so much nowNot at all

2. I have looked forward with enjoyment to things

As much as I ever didRather less than I used toDefinitely less than I used toHardly at all

3. I have blamed myself unnecessarily

Yes, most of the timeYes, some of the timeNot very oftenNo, never

4. I have been anxious or worried

No, not at allHardly everYes, sometimesYes, very often

5. I have felt scared or panicky

Yes, quite a lotYes, sometimesNo, not muchNo, not at all

6. Things have been getting on top of me

Yes, most of the timeYes, sometimesNo, most of the timeNo, as well as ever

7. I have had difficulty sleeping

Yes, most of the timeYes, sometimesNot very oftenNo, not at all

8. I have felt sad or miserable

Yes, most of the timeYes, quite oftenNot very oftenNo, not at all

9. I have been crying

Yes, most of the timeYes, quite oftenOnly occasionallyNo, never

10. Thoughts of harming myself

Yes, quite oftenSometimesHardly everNever

1 Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal
depression: Edinburgh Postnatal Depression Scale. British Journal of Psychiatry
150:782-786.
2 Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med
vol. 347, No 3, July 18, 2002, 194-199