MH Hyperemesis Screener©(HG-10)Form

MH Hyperemesis Screener©(HG-10)Form

This 10-statement screener is a space to reflect on how Hyperemesis Gravidarum (HG) may be impacting your mental health, it is not diagnostic. HG can carry physical, emotional, and day-to-day challenges that are often hard to put into words. This tool is designed to help bring awareness to those experiences. Ingram Screening recognizes that this can be a deeply difficult time, and there is no need to suffer in silence or navigate this alone. After submission, you’ll receive a personalized report within 24 hours that can support your own reflection or help guide conversations with your provider, partner, family, or others in your circle. If a statement doesn’t resonate, simply skip it.
First and Last Name*

First NameLast Name
Email Address (to send results/report)*
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1. I feel discouraged by how much this is disrupting my ability to function day to day.
2. My body feels unpredictable or out of my control.
3. I worry about how long this will last or whether it will improve.
4. I feel frustrated by how dependent I am on others or my circumstances right now.
5. I feel physically or socially isolated from others.
6. I have felt unheard, dismissed, or unsupported in trying to get care for how sick I have been.
7. The intensity of this experience feels emotionally overwhelming.
8. It is hard to get a break from thinking about how sick I feel.
9. I am using most or all of my energy just to get through each day.
10. I have moments where I feel emotionally overwhelmed or shut down.
Should be Empty: