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Assessment Questions

Step 1 of 30

3%

Are you currently pregnant or postpartum?*
- Pregnant
- Postpartum

How many weeks pregnant or postpartum are you?*

Is this your first baby?*
- Yes
- No

Have you had any complications with your pregnancy or delivery?*
- Yes
- No
If yes, please explain*

On average, how many hours of sleep are you getting per day?*

How would you describe your mental and emotional health at this moment?*
- Anxious
- Mixed
- Sad/Down
- Confused
- Good

What are your general thoughts toward mental health and wellness?*
- Haven’t really thought about it
- I’d like to be proactive and get ahead of any issues
- I’d like to talk through some feelings I’m having
- I’d like to address some problems I’m having

What feeling most describes you when others talk to you about your pregnancy or baby?*
- Happy. I’m excited to talk to them.
- Externally happy. Internally, confused.
- They don’t know what I’m going through.
- Anger, Jealousy or Contempt.

Are you breastfeeding your baby? Or Do you plan on or would you like to breastfeed your baby?*
- Yes
- No

Are you aware of some of the challenges new mothers face with breastfeeding? (e.g., latching, under or over supply, etc.)*
- Yes, I feel like I am prepared.
- Yes, but would like to learn more.
- No, but would like to learn.
- No, I’ll tackle this later if I need.

How aware are you of how nutrition, mental and physical health can impact milk supply and breastfeeding?*
- Haven’t really thought about it
- I’m not interested
- I’d like to learn more
- I’m knowledgeable in this matter

What are your thoughts toward formula and bottle feeding?*
- I do/will heavily rely on formula
- I feel ok relying on formula because/if I need to
- I would/do feel guilty if I needed to rely on formula
- I plan on supplementing breastfeeding with formula

How would you describe how you manage your schedule?

Do you plan to sleep train your child?*
- Yes, I’ve already started.
- Yes, I plan to.
- Not interested
- Undecided, would like to learn more

How familiar are you with the latest safety recommendations as it relates to a child’s sleep environment?

How familiar are you with colic, digestive issues, and/or common habits impacting sleep patterns?

How would you describe your nutritional habits at this point in time?

How aware are you regarding how nutrition can impact your pregnancy, delivery and postpartum health?

At this time, how important is your health, exercise and nutrition?

Are you having any chronic physical pain?*
- Yes
- No
If yes, please describe*

How familiar are you with urinary incontinence, diastasis recti, and pelvic floor conditioning?

How would you describe your relationship with your partner?*
- Not in a relationship at this time
- Supporting and fulfilling
- Mostly good with some struggles
- Arguing all the time

What phrase do you most identify with?*
- My baby is my main focus at this time.
- I would like to focus on my career as well as motherhood.
- I would like to find time to maintain friendships and relationships.
- I would like to use my free time pursuing my interests.

You’ve completed your maternal wellness assessment!

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