Well-being Health History

We are here to help.

Are you aware of a personal or family history of mental health challenges?  

If so, let us know who? (circle all that apply): 

SELF    MOM   DAD  SISTER(S)   BROTHER(S)  GRANDMOTHER(S)   GRANDFATHER(S)  

AUNT(S)  UNCLE(S)

If you’ve circled any of the above, please share which disorders or challenges you or a family member experienced on the line below.

These could include a range of challenges, such as: 

Depression    WHO: ________________

Anxiety WHO: ________________ 

OCD WHO: ________________

Intrusive unwanted thoughts WHO: ________________

Eating disorder  WHO: ________________

Bipolar disorder (I or II) WHO: ________________ 

Personality disorders (like

borderline personality disorder) WHO: ________________

Non-Suicidal Self-Harm (like cutting) WHO: ________________

PTSD WHO: ________________

Severe Mental Illness WHO: ________________

(like schizophrenia)

Substance use disorder WHO: ________________ 

(such as high alcohol 

or cannabis intake, opioid RX 

or illicit drug use) 

Other WHO:________________

Please share anything else that would be helpful for us to know:

__________________________________________________________________

If you have experienced one or more of the challenges or conditions above, have you received treatment before? If so, please share the type of treatment, such as seeing a therapist or trying a prescription drug like Zoloft. Leave blank if you haven’t had treatment for the disorder/challenge.

Depression    Treatment: ____________________ Current □ Previous □ 

Anxiety Treatment: ____________________ Current □ Previous □

OCD Treatment: ____________________ Current □ Previous □

Intrusive unwanted thoughts Treatment: ____________________ Current □ Previous □

Eating disorder  Treatment: ____________________ Current □ Previous □ 

Bipolar disorder (I or II) Treatment: ____________________ Current □ Previous □ 

Personality disorders (like

borderline personality disorder) Treatment: ____________________ Current □ Previous □

Non-Suicidal Self-Harm (like cutting) Treatment: ____________________ Current □ Previous □

PTSD Treatment: ____________________ Current □ Previous □

Severe Mental Illness Treatment: ____________________ Current □ Previous □

(like schizophrenia)

Substance use challenges Treatment: ____________________ Current □ Previous □

(such as high alcohol 

or cannabis intake 

or illicit drug use) 

Other ________________________ Treatment:____________________ Current □ Previous □ 

Are you currently under the care of a psychiatrist (who prescribes drug treatments for any of the above) or therapist? If so please provide their name(s) (and phone number if you have it):  ____________________________________________________________________________________

Fertility History

Did you have difficulty conceiving? 

Have you received infertility treatment? □YES □NO

If so, what type of treatment and for how long? _________________________________________

Sleep

Do you have a history of sleep difficulties outside of pregnancy or the postpartum?   □YES □NO 

Please explain: _______________________________________________________________________

Breastfeeding History and Hopes

Have you tried breastfeeding in the past? □YES □NO □NA

If so, how did it go? ______________________________________________________________

Do you plan to breastfeed with this pregnancy? □YES □NO □Unsure 

Prior Pregnancies/Births

Have you had prior pregnancies?  □YES □NO  If so, how many? ____________ (regardless of outcome)

Did you find that your pregnancy, birthing or postpartum experiences were complicated, severe or traumatic?  

□YES □NO  If yes, please explain __________________________________________________

Have you had a miscarriage, stillbirth or loss of an infant □YES □NO □NA

Do you have other children in the home?  □YES □NO  If so, how many and what ages? ____________

Partner, and Family & Friend Network

What’s your current relationship status, do you have a partner? Circle what applies:

SINGLE         MARRIED       WIDOWED      COMMITTED-RELATIONSHIP-LIVING-TOGETHER     COMMITTED-RELATIONSHIP-NOT-LIVING-TOGETHER  

Do you have a family and/or friend network (e.g., individuals you can count on for practical help and/or to talk through difficulties)?  □YES □NO

Please Explain: _________________________________________________________________

Do you feel you could ask your partner, family, or friend network for practical help and/or to talk through difficulties?

Please explain ________________________________________________________________________

Misc. Insights that Can Impact Your Mental Health and Well-Being 

Are your partners (circle): MEN    WOMEN    BOTH     OTHER  NONE  □ Prefer not to answer 

Do you currently use tobacco or vape? □YES □NO □ Prefer not to answer 

If yes, how much/how often?_________ 

Do you currently drink alcohol? □YES □NO□ Prefer not to answer   

If yes, how much/how often?_________ 

Do you currently use cannabis or cannabis products like CBD? □YES □NO □ Prefer not to answer 

If yes, how much/how often?_________ 

Do you have concerns about drug use and want help?  □YES □NO 

Do you have guns in your home? □YES □NO 

Have you ever been a victim of unwanted sexual pressure, sexual abuse, or sexual violence? □YES □NO □ Prefer not to answer 

Do you currently feel physically safe at home? □YES □NO □ Prefer not to answer 

Are you concerned about where you will live or get your next meal? □YES □NO □ Prefer not to answer 

Do you have concerns about eating and/or pregnancy, weight gain or loss?  □YES □NO 

© 2025, The Policy Center for Maternal Mental Health. This work is openly licensed via CC BY 4.0