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Edinburgh Form Edinburgh Form & Plan of Action Form 1 Revised 7/2020 Which Caregiver was involved? (Select one) Date of Activity: / / Program Becoming a Mom Family Planning Maternal Child Health (MCH/M&I) Pregnancy Maintenance Initiative (PMI) Teen Pregnancy Kansas Connecting Communities If MCH/M&I was selected, is this Edinburgh being provided to a mother during an MCH encounter for the child? Yes No If yes, what is the client’s primary healthcare coverage? None/Self Pay Private Insurance TRICARE KanCare/Medicaid CHIP (Formerly HealthWave) Medicare (client is on disability) Unknown/Not reported If yes, what is the client’s secondary healthcare coverage? None/Self Pay Private Insurance TRICARE KanCare/Medicaid CHIP (Formerly HealthWave) Medicare (client is on disability) Unknown/Not reported If yes, what is the Household Size (number of people living in the household): If yes, what is the Annual Household Income? Less than $10,000 $10,000 to $14,999 $15,000 to $19,999 $20,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 or more Don't Know Refused Edinburgh Screening 1. I have been able to laugh and see the funny side of things: As much as I always could Not quite so much Definitely not so much now Not at all 2. I have looked forward to things with enjoyment: As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all 3. I have blamed myself unnecessarily when things went wrong: Yes most of the time Yes some of the time Not very often No never 4. I have been anxious or worried for no good reason: No not at all Hardly ever Yes sometimes Very often 5. I have felt scared or panicky for no good reason: Yes, quite a lot Yes sometimes No, not much No, not at all 6. Things have been getting to me: Yes most of the time I haven’t been able to cope at all Yes sometimes I haven’t been coping as well as usual No most of time I have coped quite well No I have been coping as well as ever 7. I have been so unhappy that I have had difficulty sleeping: Yes most of the time Yes sometimes No not very often No not at all 8. I have felt sad or miserable: Yes most of the time Yes quite often Not very often No not at all 9. I have been so unhappy that I have been crying: Yes most of the time Yes quite often Only occasionally No never 10. The thought of harming myself has occurred to me: Yes quite often Sometimes Hardly ever Never Total score: Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of 150:782-786. Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199. Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title, and the source of the paper in all reproduced copies.