Fillable PERINATAL ANXIETY SCREENING SCALE (PASS)

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PERINATAL ANXIETY SCREENING SCALE (PASS)

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PERINATAL ANXIETY SCREENING SCALE (PASS)
ANTENATAL
POSTNATAL
DATE:
Weeks pregnant (
)
Baby’s age (
)
OVER THE PAST MONTH, How often have you experienced the following? Please tick
the response that most closely describes your experience for every question.
Not at all
Some
times
Often
Almost
Always
1. Worry about the baby/pregnancy
0
1
2
3
2. Fear that harm will come to the baby
0
1
2
3
3. A sense of dread that something bad is
going to happen
0
1
2
3
4. Worry about many things
0
1
2
3
5. Worry about the future
0
1
2
3
6. Feeling overwhelmed
0
1
2
3
7. Really strong fears about things, eg
needles, blood, birth, pain, etc
0
1
2
3
8. Sudden rushes of extreme fear or
discomfort
0
1
2
3
9. Repetitive thoughts that are difficult to
stop or control
0
1
2
3
10. Difficulty sleeping even when I have the
chance to sleep
0
1
2
3
11. Having to do things in a certain way or
order
0
1
2
3
12. Wanting things to be perfect
0
1
2
3
12. Needing to be in control of things
0
1
2
3
14. Difficulty stopping checking or doing
things over and over
0
1
2
3
15. Feeling jumpy or easily startled
0
1
2
3
16. Concerns about repeated thoughts
0
1
2
3
17. Being 'on guard' or needing to watch out
for things
0
1
2
3
18. Upset about repeated memories, dreams
or nightmares
0
1
2
3
Not at all
Some
times
Often
Almost
Always
Continued on Back
Not at all
Some
times
Often
Almost
Always
19. Worry that I will embarrass myself in
front of others
0
1
2
3
20. Fear that others will judge me negatively
0
1
2
3
21. Feeling really uneasy in crowds
0
1
2
3
22. Avoiding social activities because I
might be nervous
0
1
2
3
23. Avoiding things which concern me
0
1
2
3
24. Feeling detached like you're watching
yourself in a movie
0
1
2
3
25. Losing track of time and can't remember
what happened
0
1
2
3
26. Difficulty adjusting to recent
changes
0
1
2
3
27. Anxiety getting in the way of being able
to do things
0
1
2
3
28. Racing thoughts making it hard to
concentrate
0
1
2
3
29. Fear of losing control
0
1
2
3
30. Feeling panicky
0
1
2
3
31. Feeling agitated
0
1
2
3
Not at all
Some
times
Often
Almost
Always
Global Score
Reference:
Somerville, S., Dedman, K., Hagan, R., Oxnam, E., Wettinger, M., Byrne, S., Coo, S., Doherty,
D., Page, A.C. (2014).
The Perinatal Anxiety Screening Scale: development and preliminary validation. Archives of
Women’s Mental Health, DOI: 10.1007/s00737-014-0425-8
Department of Health, State of Western Australia (2013).
Copyright to this material produced by the Western Australian Department of Health
belongs to the State of Western Australia, under the provisions of the Copyright Act 1968
(Commonwealth of Australia). Apart from any fair dealing for personal, academic, research
or non-commercial use, no part may be reproduced without written permission of the
Department of Psychological Medicine, Women and Newborn Health Service, WA
Department of Health. Please acknowledge the authors and the WA Department of Health
when reproducing or quoting material from this source.
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Completed 22 September 2020

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