Survey #1

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Survey #1

While you are between 6 weeks and 12 weeks pregnant, please fill out this form. Note that this information will be shared with your doctor.

Survey One

How are you feeling today (5 if you are very happy, 1 if you are not): *

1

2

3

4

5

6

7

8

9

10

Are you feeling anxious or worried today? *

Sorry to hear that. We would like to help. What’s on your mind?

Is this your first pregnancy? *

How many children do you have?

How happy are you in your relationship? (5 if you are very happy, 1 if you are not):

1

2

3

4

5

6

7

8

9

10

Do you feel like you can lean on your partner for support?

Rarely

Sometimes

Always

Wonderful! What is your favorite thing they do to support you?

Please tell us what you think your partner could do to be more in tune with your need for support?

Please share with us what you have experienced (select as many as you need):

Anxiety

Depression

PTSD

Panic Disorder

Eating Disorder

Bipolar

OCD

Other

Please share what other mental health issues you have experienced (list as many as you need):

Do you have thoughts of harming yourself?

If you are human, leave this field blank.

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