Your name

Your email

Mobile Number

How do you feel today?
I hate myselfVery sad and miserableNot very goodIt is okay

Are you able to enjoy your time with your baby?
YesNoSometime, may be

When were you able to laugh with your partner or were able to make small happy conversations?
More than a month agoMore than a week ago but less than a month agoIn the last weekToday, itself

Are you scared of harming yourself or the baby?
A great dealA moderate amountNone at all

Are you getting irritated when your child cries or doesn't latch for a while?
A great dealSometimesNone at all

Do you feel like running away from your current situation with your baby?
Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree

Are you finding it difficult to walk out to your balcony or just to your living room area?
Very difficultDifficultNeither easy nor difficultEasyVery easy

Is Washroom your happy place, where you can cry or vent out?
YesNo

Do you feel you have everything but you are not happy?
ALwaysSometimesNever

Do you feel like you shouldn't have given birth to your child?
YesNo