• Perinatal Anxiety Screening Scale (PASS)

    The results of this form are only given to Dr. Sarah Allen's clients.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Over the past month, how often have you experienced the following? Please tick the response that most closely describes your experience for every question.

  • Worry about the baby/pregnancy
  • Fear that harm will come to the baby
  • A sense of dread that something bad is going to happen
  • Worry about many things
  • Worry about the future
  • Feeling overwhelmed
  • Really strong fears about things, eg needles, blood, birth, pain, etc
  • Sudden rushes of extreme fear or discomfort
  • Repetitive thoughts that are difficult to stop or control
  • Difficulty sleeping even when I have the chance to sleep
  • Having to do things in a certain way or order
  • Wanting things to be perfect
  • Needing to be in control of things
  • Difficult stopping checking or doing things over and over
  • Feeling jumpy or easily startled
  • Concerns about repeated thoughts
  • Being 'on guard' or needing to watch out for things
  • Upset about repeated memories, dreams or nightmares
  • Worry that I will embarrass myself in front of others
  • Fear that others will judge me negatively
  • Feeling really uneasy in crowds
  • Avoiding social activities because I might be nervous
  • Avoiding things which concern me
  • Feeling detached like you're watching yourself in a movie
  • Losing track of time and can't remember what happened
  • Difficulty adjusting to recent changes
  • Anxiety getting in the way of being able to do things
  • Racing thoughts making it hard to concentrate
  • Fear of losing control
  • Feeling panicky
  • Feeling agitated
  • Should be Empty: